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The Relationship Between Geographic Variations and Overuse of Healthcare Services: A Systematic Review

Keyhani, Salomeh MD, MPH*,†; Falk, Raphael MD, MPH; Bishop, Tara MD§; Howell, Elizabeth MD; Korenstein, Deborah MD

doi: 10.1097/MLR.0b013e3182422b0f
Brief Report

Objective: To examine the relationship between overuse of healthcare services and geographic variations in medical care.

Design: Systematic Review.

Data Sources: Articles published in Medline between 1978, the year of publication of the first framework to measure quality, and January 1, 2009.

Study Selection: Four investigators screened 114,830 titles and 2 investigators screened all selected abstracts and articles for possible inclusion and extracted all data.

Data Extraction: We extracted data on rates of overuse in different geographic areas. We also extracted data on underuse, if available, for the same population in which overuse was measured.

Results: Five papers examined the relationship between geographic variations and overuse of healthcare services. One study in 2008 compared the appropriateness of coronary angiography (CA) for acute myocardial infarction in high-cost areas versus low cost areas in the Medicare population and found largely similar rates of inappropriateness (12.2% vs. 16.2%). A study in 2000 using national data concluded that overuse of CA explained little of the geographic variations in the use of this procedure in the Medicare program. An older study of Medicare patients found similar rates of inappropriate use of CA (15% to 17% vs. 18%), endoscopy (15% vs. 18% 19%), and carotid endarterectomy (29% vs. 30%) in low-use and high-use regions. A small area reanalysis of data from this study of 3 procedures found no evidence of a relationship between inappropriate use of procedures and volume in 23 adjacent counties of California. Another 2008 study found that inappropriate chemotherapy for stage I cancer was less common in low-cost areas compared with high-cost areas (3.1% vs. 6.3%).

Conclusions: The limited available evidence does not lend support to the hypothesis that inappropriate use of procedures is a major source of geographic variations in intensity and/or costs of care. More research is needed to improve our understanding of the relationship between geographic variations and the quality of care.

Supplemental Digital Content is available in the text.

*Division of General Internal Medicine, University of California at San Francisco

HSR&D Research Enhancement Award Program San Francisco VA Medical Center, San Francisco, CA

Department of Emergency Medicine, University of California at San Francisco

§Departments of Public Health and Medicine, Weill Cornell Medical College

Health Evidence and Policy

Division of General Internal Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, NY

Supported by the Commonwealth Fund. Dr Keyhani is also supported by a VA HSR&D Career Development Award.

The views expressed in this article are those of the authors.

The authors declare no conflict of interest.

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

Reprints: Salomeh Keyhani, MD MPH, Division of General Internal Medicine University of California at San Francisco San Francisco VA Medical Center 4150 Clement (111A1) San Francisco, CA 94121. E-mail:

© 2012 Lippincott Williams & Wilkins, Inc.