Dartmouth Atlas Finds Vast Regional Differences in Medicare-Backed Elective Surgery Rates

Whether or not Medicare patients undergo elective surgery depends on where they live and their doctors, according to a report from the Dartmouth Atlas Project and the Foundation for Informed Medical Decision Making.

Researchers found remarkably wide regional variations in elective surgery for Medicare patients even though they had similar conditions.

•   Men over 65 with early-stage prostate cancer in San Luis Obispo, CA are 12 times more likely to have surgery to remove their prostate than those in Albany, GA.
• Medicare patients with heart disease in Elyria, OH were 10 times more likely to have a procedure such as angioplasty or stents than those in Honolulu, HI.
•  Women over 65 living in Victoria, TX were seven times more likely to undergo mastectomy for early-stage breast cancer than women in Muncie, ID.

“These striking variations are the by-product of a doctor-centric medical delivery system. In highlighting the variation from community to community for elective procedures, we hope to shine a light on the fact that patients’ preferences are not always taken into account when medical decisions are made,” says Shannon Brownlee, lead report author and instructor at the Dartmouth Institute for Health Policy and Clinical Practice.

The report is the first in a series looking at individual states and regions, and highlights Minnesota in addition to presenting national trends. Researchers analyzed the rates of elective or ?preference-sensitive? procedures, including:

• mastectomy for breast cancer;
• coronary artery bypass surgery;
• percutaneous coronary intervention;
• back surgery;
• knee and hip joint replacement;
• carotid artery surgery;
• gall bladder removal;
• radical prostatectomy for prostate cancer;

The report also advocates for shared decision-making to help patients understand their choices and share treatment decisions with their clinicians. The report also describes the treatment choices available for the preference-sensitive procedures, all of which can?but do not have to be? treated with surgery, as well as steps patients can take to make sure they get the care they want and need.

?All too often, patients facing elective surgery are not given an opportunity to learn about the full range of options, and that each choice has unique risks and benefits. Many are not even aware that the decision about an elective procedure is actually a choice. Instead, they routinely delegate such important decisions to their clinicians, with the result being that patients often do not get the treatment they would prefer,? says David C. Goodman, MD, report co-author and co-principal investigator for the Dartmouth Atlas Project, and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice.

The researchers explain that differences in clinicians? personal beliefs and opinions contribute to the variation in surgical rates in observed geographic locations. For example, there is considerable disagreement among surgeons about the need for back surgery, its effectiveness, and even the best way to diagnose the cause of back pain. With no consensus about how to diagnose and treat back pain, the rate of back surgery varies widely from place to place.

As a result, Medicare patients living in Casper, WY are nearly six times more likely to undergo back surgery than patients living in the Bronx, NY.

?Some of the most important choices in medicine are not the clinician?s alone to make. Patient preference is especially important when facing a test, surgery or treatment that is elective. In order to ensure that patients get the treatment that is right for them, the choice should be a shared decision. When done right, shared decision-making results in a better decision: a personalized choice based on both the best scientific evidence and the patient?s values,? says Michael J. Barry, MD, report co-author and president of the Foundation for Informed Medical Decision Making.

The Dartmouth Atlas Project is located at the Dartmouth Institute for Health Policy and Clinical

Click here for the full report, Improving Patient Decision-Making in Health Care: A 2011 Dartmouth Atlas Report Highlighting Minnesota.