Heart experts agree – you should be prescribed certain heart drugs known as beta-blockers and statins after a heart attack. Yet Americans in San Angelo, Tex., are far more likely to get a beta-blocker than people living in Salem, Ore.
A new study released Tuesday shows there seems to be little rhyme or reason for these differences across American regions, states and counties. In some places a certain drug is prescribed far more often than it is in other places. The study, published by the Dartmouth Atlas project, adds to a growing body of evidence showing just how disorganized and illogical U.S. healthcare can be.
“There is no good reason why heart attack victims living in Ogden, Utah, are twice as likely to receive medicine to lower their cholesterol and their risk of another heart attack than those in Abilene, Texas, but this inconsistency reflects the current practice of medicine in the United States,” says Dr. Jeffrey Munson, assistant professor at The Dartmouth Institute for Health Policy & Clinical Practice.
The Dartmouth Atlas, a project that studies and documents variations in medical care across the United States, took a look at prescriptions written for and filled by patients on Medicare, the federal health insurance plan for people over 65.
The researchers looked at several types of prescription medication – blood pressure and cholesterol drugs that should be prescribed after a heart attack; bone-building drugs for elderly people who have broken a bone; drugs known to be harmful in the elderly, such as Valium; and so-called discretionary drugs, whose benefits in everyone aren’t clear-cut.
For the heart attack drugs and bone drugs, the patterns should have been consistent. Experts agree about their benefits and no doctor should be unaware of the value of giving a heart attack patient drugs to control blood pressure and cholesterol.
Yet in San Angelo, Texas, 91 percent of heart attack patients filled a prescription for a beta-blocker drug to lower blood pressure in 2008 or 2009, the study found. But in Salem, Ore., just 62.5 percent did. For a statin drug to lower cholesterol, the rates ranged from 91 percent of patients in Ogden, Utah to 44 percent in Abilene, Tex.
And for osteoporosis drugs, the rates were lower everywhere. The National Committee for Quality Assurance, a non-profit group that advocates for good health care, suggests that anyone with osteoporosis who breaks a bone should get drugs to stop the bone-thinning condition. Yet only 14 percent of the Medicare patients who had such a fracture got one of these drugs. The numbers ranged from 28 percent in Honolulu to 6.8 percent in Newark, N.J.
Even odder – the rates did not correlate. “We found that regions with high use of beta blockers don’t necessarily have high rates of statin use,” Dartmouth's Dr. Nancy Morden, who also worked on the report, told reporters in a conference call.
The team at the Dartmouth Atlas lay the blame squarely at the feet of doctors and other medical professionals who prescribe drugs. “We are measuring the behavior of individual physicians,” Munson told reporters. Doctors everywhere should know the benefits of both statins and beta-blockers.
Other reports have shown great differences in health among Americans. Coloradans tend to be thinner and to exercise more than people in Mississippi. But the Dartmouth Atlas project did not find any clear correlation between those statistics and prescription drug use – the heart attack victims in Colorado were not so different from heart attack victims in Texas as to explain the prescription differences.
As for the drugs for which there isn’t a clear consensus, such a proton pump inhibitors (PPI) for acid stomach, again the patterns were just crazy. “Nationally, one-quarter (25.8 percent) of patients used a PPI in 2010,” the report reads.
“There was almost threefold variation in the use of PPIs across hospital referral regions. In Grand Junction, Colorado, 15.8 percent of beneficiaries filled a prescription for a PPI, while in Miami, Florida, the proportion treated was 45.5 percent.” It’s unlikely, the report says, that this kind of variation can be explained away by patient preferences or even incidence of heartburn.
There was one measure that did correlate with other medical care practices, and that was the use of drugs known to be risky, including certain types of muscle relaxants, which can damage bones, anti-anxiety drugs such as Valium and other benzodiazepines, and antihistamines that make patients sleepy.
More than a quarter of the Medicare patients filled a prescription for at least one of these drugs, the survey found, And these prescriptions were most common in the areas where the highly recommended drugs were the least likely to be prescribed.
“There was more than a threefold difference between the percent of patients treated with a high-risk medication in Rochester, Minnesota (14 percent) and the percent treated in Alexandria, Louisiana (43 percent),” Munson and Morden wrote.
“This report demonstrates how far we still have to go as a nation to make sure people get the care they need when they need it,” said Katherine Hempstead, senior program officer at the Robert Wood Johnson Foundation, which helps pay for the Dartmouth Atlas Projects, which has found big regional differences in health care costs and in the quality of care.
First published October 15 2013, 1:23 PM