The latest report from the Dartmouth Atlas Project, doesn't reinforce confidence in the equanimity of the nation's healthcare system. Again.
Rather, it reveals some troubling ethical quality and safety issues about what Dartmouth investigators are calling a "doctor-centric" medical delivery system for Medicare beneficiaries practiced in much of the country.
In eight medical conditions in which there is an aggressive elective surgery option versus other equally effective courses of care, doctors are making decisions without consideration of the patient's point of view, the Dartmouth project's authors say. In some cases, the patients probably never fully understood that other equally reasonable and effective options that didn't involve surgery were available to them.
"What often happens, [is that] providers assume that they can diagnose patient preferences, and that they can know what's important to patients," says Richard Wexler, MD, a director at the Foundation for Informed Medical Decision Making, which collaborated with the Dartmouth Atlas on this report.
"But what we're finding is that in this new day in healthcare, where much of the 'family doctor type of image' has passed, providers are really not very good at diagnosing patient preferences and they often will get it wrong. That's a strong argument for trying to engage patients in part of the decision making process."
The report issued last week, "Improving Patient Decision-Making in Health Care," revealed this phenomenon by demonstrating the wide and unexplained variation across the country in the use of more aggressive types of care in these eight surgical procedures plus prostate cancer screening.
For example, the study questions why:
• Beneficiaries in Sioux City, IA with osteoarthritis are more than five times as likely to undergo hip replacement surgery as those in Honolulu.
• Male beneficiaries 65 and older with benign prostatic hyperplasia undergo transurethral resection (TURP) in Idaho Falls at a rate five times greater than the rate for men in Terre Haute, IN.
• Women in Victoria, TX are seven times more likely to undergo radical mastectomy for early-stage breast cancer, as opposed to a lumpectomy, than women in Muncie, IN.
The bottom line, says Shannon Brownlee, the report's lead author and instructor at the Dartmouth Institute for Health Policy and Clinical Practice, is that "different doctors have different opinions about the best way to treat a given condition."
In short, the patients are not getting the full story about what's in their best interest, what suits their goals and lifestyle preferences.
"Often times, the physician's preferences and values tend to supersede the patient's," says David Goodman, MD, the report's co-author and co-principal investigator for the Dartmouth Atlas Project.
"What we found is that physicians differ very strongly in their opinions about the value of these procedures, and that there are regional differences, that one might think of almost as differences in culture of care that develop, partly related to how they are trained or the history of the practice. But often these physicians are quite unaware that they practice differently from a quite similar community halfway across the country," Goodman says.
The researchers emphasize they are not suggesting that physicians are just trying to generate income and volume, although that may, in some cases, underpin the rationale behind a more aggressive course of care.
Rather, they say, it's about making sure the patient is fully informed of all the pros and cons of every treatment option – surgical and non-surgical—and they are fully informed about the benefits and risks, recovery periods, perforations, risk of stroke and even death from having an invasive procedure versus taking drugs and changing their lifestyle.
For instance, a patient might not realize that surgery for back pain would require a two-month convalescence with limited mobility, whereas with a non-surgical option such as physical therapy, medication and exercise they may have a similar outcome.
One of the authors, Michael Barry, MD, explains the issue as one that is at the epicenter of patient safety and quality and reducing medical errors.
"The patient safety movement in the last decade has worked very hard to make sure that the wrong patient doesn't get surgery, that Mr. Jones doesn't get taken down to operating room for surgery that was scheduled for Mr. Smith, and that's really important," Barry says.
"But if Mr. Smith were fully informed, and would then decide he would neither need nor want this surgery, then taking him to the operating room is like operating on the wrong patient as well."
Here's an example of how doctors aren't correctly informing patients, Barry continues. When a large cohort of Medicare patients who had undergone elective stent procedures for chest pain or stable angina were asked why they had the procedure, "three-fourths said, 'I did it to prevent a heart attack or to live longer.' But we have randomized trials with tens of thousands of patients that say that's not what stenting is about. It can reduce angina, although patients treated medically can catch up over a couple of years," Barry says.
Meanwhile, stenting in and of itself carries risks of generating clots or strokes, heart attacks, and even death.
Barry points out that in studies that made sure patients had all information about procedures available for their conditions, they were 20% more likely to make more conservative decisions than their doctors recommended.
The report explained in detail courses of care for eight procedures for which non-surgical options are just as reasonable to recommend.
For example, "there is little evidence that surgery is better than non-surgical treatment for chronic or persistent non-specific low back pain in patients who do not also have leg pain." Often the pain goes away on its own, yet surgery is risky and often patients are no better – and sometimes worse off – than before.
Nevertheless, rates of back surgery vary six-fold, depending on what part of the country a patient happens to reside. For example in Casper WY, surgeons perform 10 surgeries per 1,000 Medicare patients while in Honolulu, the percent is 1.7 and across the U.S., the rate is 4.3.
A similar story unfolds with stable angina. Patients so diagnosed have the option to be treated with medications and lifestyle change or with medications, stenting, or surgery.
But there is a trade-off. Stenting and surgery carry their own short-term risks, such as stroke, heart attack, and death. Yet in Elyria Ohio, beneficiaries are 10 times more likely to undergo percutaneous coronary intervention than those in Honolulu. And patients in McAllen, TX are four times more likely to undergo a coronary artery bypass graft procedure than those in Pueblo, CO.
The latest Atlas report documents variation for 306 hospital referral regions, and about 3,000 residential zip code regions.
For Brownlee, the variation boils down to questions of ethics about how much physicians are fully informing their patients. "The reason to be concerned about shared decision making is because it's the right thing to do. We have to make sure patients are really fully informed about their options, and that they get to choose the elective procedure that's the right one for them. At its very heart, it's an ethical issue."
I think the latest Atlas tome has it right. The decision on course of care should be one that doctors make with a patient or the family. The days when doctors tell patients "This is what we're going to do for you..." without explaining the options, should be over.
Wexler sums up that there are two underlying ethical principles at work in the delivery of care. One is the duty of the physician to do what the physician believes is in the best interest for the patient. But the second is to respect that the individual has a right to say what will happen to his or her body. "We have an ethical obligation to respect that autonomy ... But we have allowed habit, bias, and financial incentives to creep into this equation."