Your home & your health: Does geography impact medicine? Does it matter whether a region is surrounded by large bodies of water, encircled by towering mountain peaks or that its residents share a common ancestry? Consider Switzerland, a nation with a highly developed economy replete with advanced technological and medical infrastructure. Despite these advantages, less than a century ago, goiter and its progression to myxedema created some vexing public health dilemmas.1
Over 80% of young men and 60% of school children developed sizable swelling of their necks, with some of the afflicted suffering from the most extreme hazards of thyroxine deficiency, severe growth retardation and stunting of neuro-intellectual development. In their effort to draft healthy men, Swiss Army recruiters observed that the vast majority of individuals with thyroid gland enlargement resided in villages dotting the scenic, rugged Alps. As Mark Twain wittily observed: “I have seen the principal features of Swiss scenery—Mount Blanc and the goiter—and now for home.”1
A landlocked country nestled thousands of miles away from any ocean, the natural reservoirs of iodine, Switzerland’s soil lacked this nutrient critical to thyroid hormone synthesis. Diligent medical sleuthing identified and corrected this endocrine anomaly, and the commonplace iodination of table salt has made this problem vanish.
Examples of geography affecting health and disease abound. The Silk Road was an ancient network of trade routes created by the natural geographic features of Europe and Asia that stretched from the Korean Peninsula to the Mediterranean Sea. It became a thoroughfare used by itinerant traders to bring their wares to foreign markets. Some of these travelers stopped and settled along the way, establishing communities that were enriched by the addition of new sources of genetic material, including novel genes, such as ERAP1 and NOD1, that are critical to the development of autoimmunity and, in particular, the periodic fever syndromes, such as Behçet’s disease (see Rheuminations, “Inflammatory Origin of Fever Is Key to Diagnosis,” September 2014).
Health can also be affected by the direct effects of macro- and micro-environmental factors. People residing near a smog-spewing industrial complex are likely to suffer a higher incidence of lung disease than those who live next to a forest preserve. The quality of the air we breathe may also play a role in the development of rheumatologic diseases and autoimmunity. This is a complex issue, with data suggesting that short-term variations in air pollution may influence disease activity in established autoimmune rheumatic disease in humans, such as lupus, scleroderma and rheumatoid arthritis.2,3
Sometimes, the culprit may reside indoors. It has been observed that antigens released by decaying cockroach carcasses pose the highest risk for the development of childhood asthma in many of our inner-city neighborhoods.4 Merely focusing on outdoor air quality will not fix this issue for these children.
On a broad scale, one’s community exerts a profound effect on one’s longevity. Indeed, it matters where you live. The U.S. counties with the longest life expectancy are affluent areas with high per capita incomes, such as Marin County, Calif., and Summit County, Colo., whereas Oglala Lakota County, S.D., which includes the Pine Ridge Native American reservation, many counties clustered along the lower Mississippi River Valley and parts of West Virginia and Kentucky have the shortest life expectancy, with the difference exceeding 20 years (87 vs. 67 years). This worrisome national gap in life expectancy resembles the difference observed between Japan, an advanced nation, and India, a developing one.5 There is no sign of the American gap closing; in fact, from 1980 to 2014, it increased by an additional two years.
A Costly Paradox
Because the U.S. can be divided into distinct geographic regions, may there be distinct variations in healthcare consumption and its cost in each of these areas? Considerable data have been amassed, demonstrating that the quality and cost of medical services vary wildly in different parts of the country.6 A report commissioned by Blue Cross and Blue Shield, an organization of insurers that covers about one-third of Americans, analyzed three years of claims data from 64 markets. Researchers found that knee replacement surgery is most expensive along the Eastern and Western seaboards, the Great Lakes and parts of Texas, and it’s least costly in the farm belt and the Rocky Mountain states.
But the data reveal a more curious observation: Within each of these regions stark differences in the cost of care exist. Although the national average list price for knee joint arthroplasty surgery was $31,124, this number is meaningless considering that the standard deviation of prices was so wide. In Dallas, the cost of the identical procedure varied between $16,772 and $61,585. In Boston, a city where nothing is cheap, the price of a total hip replacement varied four-fold, between $17,910 and $73,987. Perhaps I should advise my patients to fly down to Birmingham Ala., where the cost of the same hip procedure averages a paltry $11,327. Throw in a stay at a five-star hotel and a couple of tickets to see the Crimson Tide play football and you have an amazing deal!
None of this pricing makes sense, particularly when one realizes that no major study has found an association linking the cost of services to quality of care. This lack of a correlation between cost and quality is stunningly consistent across a range of services and procedures. In one recent analysis, researchers using U.S. Medicare data found an inverse relationship between the quality of surgery and its cost. Ponder that for a moment: Higher cost was associated with poorer outcomes—including greater complication rates for all procedures studied, including coronary artery bypass graft, colectomy and aortic aneurysm repair.7
Before we, as cognitive specialists gloat, the results extend beyond surgeons. A recent study observed a wide variation in what internists and hospitalists spent in their diagnostic evaluation of patients and once again, it found no added benefit gained with higher spending.8 When it comes to providing quality medical care, money can’t buy you everything.
Perhaps a more distressing set of results was observed in a study that compared the provision of low-value health services by primary care doctors in community-based practices to those who were hospital employed.9 The services compared included the use of antibiotics for upper respiratory tract infections, computed tomography or magnetic resonance imaging for back pain and headache, radiographs for upper respiratory tract infections and back pain, and specialty referrals for these three conditions.
Visits to hospital-based practices were associated with greater use of low-value computed tomography and magnetic resonance imaging, radiographs and specialty referrals than visits to community-based practices, and visits to hospital-owned community-based practices had more specialty referrals than visits to physician-owned community-based practices. If confirmed by others, these results will cast serious doubt on the cost-effectiveness claims made by large hospital-based systems and their reasons for expanding their physician networks.
It matters where you live. The U.S. counties with the longest life expectancy are affluent areas with high per capita incomes, such as Marin County, Calif., and Summit County, Colo., whereas Oglala Lakota County, S.D., which includes the Pine Ridge Native American reservation, many counties clustered along the lower Mississippi River Valley & parts of West Virginia & Kentucky have the shortest life expectancy, with the difference exceeding 20 years.
Variations on a Theme
Why is there such variation in the delivery and the quality of healthcare? With all the available technology, one might surmise that it would be far easier for practitioners to quickly adapt to newer insights and recommendations and adjust their behaviors accordingly. This has yet to be observed.
Consider what goes on in our small area of the medical map. If one studies the cohort of patients referred to a rheumatologist, it is likely that a sizable number of them are being sent to us for the wrong reasons. Think about the patient with fatigue and normal lab tests except for a low titer antinuclear antibody (ANA), or the retiree with bilateral shoulder pain who has already undergone costly and unremarkable magnetic resonance imaging tests (MRI) ordered by someone searching for torn tendons, when the obvious cause of the abrupt onset of pain was polymyalgia rheumatica. In endemic areas, there is the ubiquitous Lyme disease conundrum, where a misunderstanding of Western blot antibody results may lead the physician and the patient down a perilous path of lengthy and unnecessary antibiotic therapy. Although we may not want to admit it, the consumption of low-value services can generate a steady flow of patients.
None of this pricing makes sense, particularly when one realizes that no major study has found an association linking the cost of services to quality of care. This lack of a correlation between cost & quality is stunningly consistent across a range of services & procedures.
Changing the behaviors of other doctors by educating them about our diseases would be the ideal way to correct this problem, but this is a highly impractical solution for several reasons. First, most doctors are not very interested in learning about our diseases—a sad fact, but true. Those who are intrigued often become rheumatologists, and there are currently only 6,000 of us, less than 1% of the 900,000 doctors practicing in the U.S.10
Second, there is the impact of the modern healthcare culture that insists that each minute of the day be productive. This has made it challenging to find the time for clinicians to halt their activities and attend a lecture or rounds.
Third, some deeply ingrained biases may contribute to the variations in care provided by doctors. In one large national study, the spending patterns of general internists and family physicians were tracked over the course of several years. Those who trained in residency programs that were based in high-spending regions of the country continued to spend more than their peers who trained in lower spending areas.11 So perhaps there is a psychological basis for ordering that questionable ANA or Lyme titer test or those costly MRI studies. Take notice fellow program directors: Once established in training, spending habits may be difficult to break.
Finally, some of the variations in how we care for our patients may be based on gender differences. The evidence suggests that female physicians are more likely to adhere to clinical guidelines and evidence-based practice than their male counterparts.12 Whether patient outcomes differ between male and female physicians was recently confirmed in a study of mortality and readmission rates among Medicare inpatients.13 Elderly hospitalized patients treated by female internists had significantly lower mortality and readmission rates compared with those cared for by their male counterparts. Guys, it’s time to start playing by the rules!
Based on a recent study, the treating physician’s age may affect patient mortality.14 The variations that affect medical practice are numerous and highly complex. It will take considerable effort to skew the onerous ones in a favorable direction.
Complexity trumps any simple solutions.
Simon M. Helfgott, MD, is associate professor of medicine in the Division of Rheumatology, Immunology and Allergy at Harvard Medical School in Boston.
In the article, “Make Rheum for Trainees,” May 2017, Heather Ferri, DO, was mistakenly identified as an MD. We regret the error.
- Zimmermann MB. Research on iodine deficiency and goiter in the 19th and early 20th centuries. J Nutr. 2008 Nov;138(11):2060–2063.
- Deane KD, Norris JM, Holers VM. Pre-clinical rheumatoid arthritis: Identification, evaluation and future directions for investigation. Rheum Dis Clin North Am. 2010 May;36(2):213–241.
- Bernatsky S, Fournier M, Pineau C, et al. Associations between ambient fine particulate levels and disease activity in patients with systemic lupus erythematosus (SLE). Environ Health Perspect. 2011 Jan;119(1):45–49.
- Arruda LK, Vailes LD, Ferriani VP, et al. Cockroach allergens and asthma. J Allergy Clin Immunol. 2001 Mar;107(3):419–428.
- Roth GA, Dwyer-Lindgren L, Bertozzi-Villa A, et al. Inequalities in life expectancy among US counties, 1980 to 2014. JAMA Intern Med. 2017 May 8;317(19):1976–1992.
- Millman J. A knee replacement surgery could cost $17k or $61k. And that’s in the same city. The Washington Post. 2015 Jan 21.
- Birkmeyer JD, Gust C, Simick JB, et al. Hospital quality and the cost of inpatient surgery in the United States. Ann Surg. 2012 Jan;255(1):1–5.
- Tsugawa Y, Jha AK, Newhouse JP, et al. Variation in physician spending and association with patient outcomes. JAMA Intern Med. 2017 May 1;177(5):675–682.
- Mafi JN, Wee CC, Davis RB, et al. Association of primary care practice location and ownership with the provision of low-value care in the United States. JAMA Intern Med. 2017 Jun 1;177(6):838–845.
- Young A, Chaudhry HJ, Pei X, et al. A census of actively licensed physicians in the United States. J Med Regulation. 2015;101(2):8–23.
- Chen CC, Peterson S, Phillips R, et al. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014 Dec 10;312(22):2385–2393.
- Berthold HK, Gouni-Berthold I, Bestehorn KP, et al. Physician gender is associated with the quality of type 2 diabetes care. J Intern Med. 2008 Oct;264(4):340–350.
- Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs. female physicians. JAMA Intern Med. 2017 Feb 1;177(2):206–213.
- Tsugawa Y, Newhouse JP, Zazlavsky AM, et al. Physician age and outcomes in elderly patients in hospital in the US: Observational study. BMJ. 2017 May 16;357:j1797.