By the early 1980s, Wennberg et al., using small area analysis and geographic information systems analytic techniques, demonstrated that a significant amount of nonrandom medical practice variability existed between clinical practices in different geographic locales, despite treating clinically similar patients (Barnes, O'Brien, Comstock, D'Arpa, & Donahue, 1985; McPherson, Wennberg, Hovind, & Clifford, 1982). In their study they examined the incidence of several common surgical procedures in seven hospital service areas in southern Norway, 21 sites in the United Kingdom, and 18 sites in the northeastern US. Although overall surgical rates were higher in the US than in the United Kingdom or Norway, there was significant variability in surgical rates among sites. In addition the variability was similar across all the three countries. In fact there was surprising consistency among countries in the rank order of variability for most procedures: tonsillectomy, hemorrhoidectomy, hysterectomy, and prostatectomy varied more from area to area than did appendectomy, hernia repair, or cholecystectomy. Thus this variation appeared to be nonrandom and not related to the organization or financing of care across the three countries (McPherson et al.).
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