Kids' Health Care Quality Varies Geographically (STUDY)

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By Sharon Begley

NEW YORK, Dec 11 (Reuters) - Children in Lebanon, New Hampshire, are more than twice as likely to have their tonsils removed as those in Bangor, Maine. Kids in Lewiston, Maine, are 50 percent more likely to have a CT scan of their head than are kids in Portland, Maine, or Lebanon and Burlington, Vermont.

Lebanon's children don't have especially infection-prone tonsils, and Lewiston's don't fall on their heads more than kids elsewhere do. Instead, according to a report released on Wednesday, the glaring variation means that in some cases "children are not receiving enough good care," said pediatrician and health policy analyst Dr David Goodman of the Geisel School of Medicine at Dartmouth University, who led the study for the Dartmouth Atlas Project. But in other cases they "may be receiving unnecessary care that is harmful."

Similar research from the project has shown that the rate of medical procedures performed on older Americans covered by Medicare varies enormously depending on where they live.

The new report, which focused on northern New England, is the first to show that geographic variability exists in children's healthcare, too, raising questions about why tens of thousands of kids are not receiving recommended care such as screening for lead poisoning and why tens of thousands of others are subjected to potentially unneeded treatments such as CTs for stomachaches.

The Dartmouth Atlas was able to examine geographic variations in the medical care provided to children in Maine, New Hampshire and Vermont from 2007 to 2010 because those states are among the few that collect data on all health insurance claims, which the researchers analyzed.

"This suggests that there is a significant amount of overuse of medical services in some areas," said Dr Vikas Saini, a cardiologist and president of the Lown Institute, a healthcare think tank in Boston. "Especially because unneeded care can expose children to harmful side effects, this is very troubling."

PROCEDURES TO AVOID

The idea that Americans undergo millions of unneeded procedures every year has become more widely recognized as a result of the Choosing Wisely campaign, in which medical specialty societies have for the past two years identified procedures that should be avoided or questioned.

That whether a child undergoes a procedure depends in part on where he or she lives has been known since the 1970s, when researchers led by Dr John Wennberg of Geisel found that rates of tonsillectomy are 60 percent in some places and less than 20 percent in others. The difference, they found, could not be explained by underlying medical conditions among the children, and was instead more likely due to the local medical culture: Some doctors believe in removing tonsils and others don't.

Apart from the tonsillectomy work, research on variations in the healthcare children receive has lagged that on adults.

In the new study, the researchers found regional variations in rates of hospitalizations, common surgeries, imaging, prescriptions and office visits such as for well-child care and middle-ear infections.

Children in St. Albans and Bennington, Vermont, had triple the number of annual office visits (3.6) as kids in Houlton, Maine (1.2). The presence of large medical centers, children's hospitals and, therefore, pediatricians and specialists hardly mattered: Burlington and Bangor both have such centers, but the rate of office visits was more than 50 percent higher in Burlington.

In areas with fewer pediatricians, children went to emergency rooms more often, but what happened to them there varied even more.

Some of the greatest variation occurred in "preference-sensitive" care. These are procedures, such as placing tubes in the ears, that have unclear benefits but which parents or physicians may opt for anyway. There is no consensus on which children will get fewer ear infections or less hearing loss thanks to tubes, for instance.

As a result, preference ruled: Middlebury, Vermont, has more than four times the rate of tube insertions (15.2 per 1,000 children) as Bangor (3.4). Littleton, New Hampshire, has more than four times the rate of tonsillectomies (10.9 per 1,000 children), which are also of questionable benefit, as Bangor (2.7).

Differences in how many kids get ear, nose and throat disease are unlikely to explain these differences, said Lown's Saini.

Particularly worrisome to experts is the high rate of CT scans in some places. CT delivers radiation equivalent to 200 to 400 chest X-rays, increasing the risk of cancer decades later. Children in Presque Isle, Maine, had 19.7 head CTs per 1,000, compared to 8.4 in Burlington. The American Academy of Pediatrics says head CTs are "not necessary" for the immediate evaluation of head injuries and pose "considerable danger to children."

Bennington had more than triple the rate of abdominal or chest CTs (15.4) as those in Machias, Maine (4). The variation did not depend on whether a major medical center is nearby: The rate in Bangor (11.7) was more than double that in Lebanon, (4.7), though both have large hospitals.

Use of medication for attention deficit hyperactivity disorder (ADHD) varied by a factor of 2, with 2.9 percent of Fort Kent, Maine's, children on the drugs but 8.1 percent of Ellsworth's. There was a comparable gap in use of antidepressants and antipsychotics, whose use in children has been widely criticized.

More doctors in an area did not necessarily increase the rate of questionable procedures, while fewer doctors did not reduce it. Instead, overuse is likely a result of the prevailing "medical culture," said Saini: Doctors who walk the same hospital corridors and socialize through the same professional and other organizations trade anecdotes about what works.

"Most of what we do in medicine doesn't have empirical evidence" for whether it works and for whom, said Saini. "Instead, it's driven by anecdotal evidence and professional opinion," which doctors who practice in the same area are likely to hear about and be influenced by, especially early in their careers.

Although the Dartmouth researchers underlined the overuse of some medical procedures in some places, they also found worrisome underuse of proven therapies. Practice guidelines call for strep throat to be treated with antibiotics. More than 90 percent of such cases were properly treated in Exeter and Derry, New Hampshire, while only 41 percent to 47 percent were in Calais, Presque Isle, and Houlton, Maine.

The Dartmouth Atlas Project published the data at www.dartmouthatlas.org. (Reporting by Sharon Begley; Editing by Douglas Royalty)

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Couples' Drinking Habits May Predict Likelihood Of Divorce, Study Finds

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A new study concludes that heavy drinking isn't a marital deal-breaker -- so long as both spouses are consuming the same amount of alcohol.

Researchers at the University at Buffalo followed 634 couples through the first nine years of marriage and discovered that couples who drink similar amounts of alcohol on average are more likely to have a successful marriage than couples who differ in their drinking patterns.

Specifically, 50 percent of couples in which one partner was imbibing significantly more than their spouse ended up divorcing. However, that number dropped to 30 percent for couples who possessed similar drinking habits, regardless of if they were heavy or light drinkers.

“Our results indicate that it is the difference between the couple’s drinking habits, rather than the drinking itself, that leads to marital dissatisfaction, separation and divorce,” Kenneth Leonard, the lead author on the study, said in a statement. Watch the video below to hear more.

It's not the first time researchers have found a link between drinking habits and divorce. Researchers from the Norwegian Institute of Public Health looked at data collected from 19,977 married couples and concluded the same thing -- those who matched in drinking habits were less likely to split.

Check out the slideshow below for more interesting divorce-related studies.

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Splitting chores could lead to divorce? According to a Norwegian study released in August 2012, the divorce rate among couples who divvy up household chores is roughly 50 percent higher than for those in which the wife handles the housework. So does that mean couples shouldn't split the chores equally? Not necessarily. Researchers say that the higher divorce rate has more to do with "modern" values and attitudes -- such as viewing marriage as less sacred -- rather than a cause-and-effect relationship.

In February 2012, Swedish scientists released a study suggesting that a specific gene may explain why some women have a hard time committing, or staying committed, should they marry. The researchers found that women who possessed a variation of the oxytocin receptor gene known as A-allele were less likely to get married due to difficulty bonding with other people. Those with the gene who did marry were 50 percent more likely to report "marital crisis or threat of divorce."

In November 2012, a 26-year longitudinal study released by the University of Michigan found that when a husband reported having a close relationship with his wife's parents, the couple's risk of divorce decreased by 20 percent. On the other hand, when a wife reported having a close relationship with her husband's parents, the couple's risk of divorce increased by 20 percent. Why the difference? Researcher Terry Orbuch told the Wall Street Journal that she believes that many wives eventually view their in-laws' input as meddlesome, while husbands tend to take their in-laws' actions less personally.

Don't ignore those pre-wedding jitters: they may warn of marital trouble ahead, according to a UCLA study published in the Journal of Family Psychology in September 2012. Researchers asked 232 newlyweds in their first marriages whether they had "ever been uncertain or hesitant about getting married" after they got engaged. The research team followed up with the couples every six months for the first four years of their marriages. In a HuffPost blog, one of the researchers, Justin Lavner, explained that premarital doubts predicted divorce rates four years later, especially when the doubtful partner was the wife. According to Lavner, "19 percent of couples in which wives had doubts were divorced four years later, but only 8 percent of couples in which wives did not have doubts ended up divorced. Husbands' doubts did not significantly predict divorce, although divorce rates were somewhat higher among husbands with doubts (14 percent) than husbands without doubts (9 percent)."

According to a study released in May 2012 by the University of Florence, “sudden coital death” is more common when a man is engaging in extramarital sex in an unfamiliar setting than when he's having sex with his spouse at home. The researchers found that infidelity outside the home was associated with "a higher risk of major cardiovascular event," including fatal heart attacks. “Extra-martial sex may be hazardous and stressful because the lover is often younger than the primary partner and probably sex occurs more often following excessive drinking and/or eating," researcher Dr. Alessandra Fisher told the Daily Mail. “It is possible that a secret sexual encounter in an unfamiliar setting may significantly increase blood pressure and heart rate, leading to increased oxygen demand.”

Living together before marriage is no longer a strong predictor of divorce, according to a study released by the Centers for Disease Control and Prevention in early 2012. As part of a marriage survey of 22,000 men and women, researchers found that those who were engaged and living together before the wedding were about as likely to have marriages that lasted 15 years as couples who hadn't cohabited. What about couples who moved in together but weren't engaged? The study found their marriages were less likely to survive to the 10- and 15-year mark.

More couples are opting for long-term marital separations because they cannot afford to divorce, according to a study conducted by Ohio State University that was published in August 2012. Researchers surveyed 7,272 people between 1979 and 2008. Most people in the study who separated from a spouse reported getting a divorce within three years of separating. But 15 percent of people who separated did not get a divorce within the first 10 years because it was too costly, especially when children were involved.

Divorce at a younger age hurts people’s health more than divorce later in life, according to a Michigan State University study released in January 2012. Sociologist Hui "Cathy" Liu looked at self-reported health information of 1,282 participants over the last 15 years, analyzing the difference in well-being between those who remained married over the course of the study and those who divorced. Among the divorced, Liu found that those who split at a younger age tended to have more health issues than those who divorced later in life. Liu said the findings suggested older people have more coping skills to deal with the stress of divorce.

In November 2012, the European Economic Review released a study that revealed women who clock an extra 12 minutes per week face a 1 percent increase in the risk of a marital breakdown. Why? Lead researcher Berkay Ozcan, PhD, explained that working more hours is a "form of insurance" for women when their marriage is on the rocks. The study also found that there is no strong evidence to suggest men do the same when divorce seems likely.

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