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Updated Friday, December 14, 2012 at 12:46 AM

Study: Decisions about surgery often hinge on where you live

By Carol M. Ostrom
Seattle Times health reporter

Patients in Wenatchee are three times more likely to have their arthritic knees replaced than are similar patients in Honolulu, while men in Bellevue are much less likely than those in Thousand Oaks, Calif., to undergo a surgical procedure for benign prostate disease, new data released this week show.

The latest statistics from the Dartmouth Atlas Project zero in on elective procedures undergone by Medicare patients in Pacific states. As is true elsewhere in the country, the prevalence of some procedures depends on where you live.

This variation, the authors say, reflects physician training and preference — not what patients want or need.

"Many patients are not even aware that the decision about elective surgery is actually a choice and that it should be theirs to make," wrote the authors. "Instead, they routinely delegate such important, even life-altering decisions to their clinicians in the belief that 'the doctor knows best.' "

The authors noted that while many doctors or hospitals try to explain the variation by saying their patients are sicker or more in need of certain procedures, there is no reason to think that patients in one area differ from any others.

In fact, many studies have found patient preferences don't vary from place to place, the authors said.

The Atlas Project has used Medicare data for more than two decades to document the wide variation in how medical resources are used in the U.S. In this and other reports, they found that "geography is destiny," in the words of Dr. David Goodman, co-author of this study and co-principal investigator for the Dartmouth Atlas Project.

The study's authors looked at rates of common elective-surgical procedures including knee and hip replacements, mastectomy for early breast cancer, two heart procedures for stable coronary disease, back surgery for low back pain, surgery for carotid-artery narrowing, surgery for nonsymptomatic gallstones, surgical treatment for enlarged prostate glands and screening and treatment for early-stage prostate cancer.

All of those conditions were ones for which doctors don't always agree as to the best treatment. The procedures also are elective — meaning there are other choices.

In Washington, the researchers identified six separate large-hospital referral regions for comparison: Everett, Olympia, Seattle, Spokane, Tacoma and Yakima. Those regions include larger hospitals or academic medical centers capable of complex procedures and surgeries.

They also looked at individual cities, which often produced startling results. For example: Patients in Thousand Oaks, Calif., with benign prostate disease were 12 times more likely than patients in Bellevue to undergo a surgical procedure called transurethral resection of the prostate.

In many cases, the rate for procedures in the Seattle hospital referral region was near or below the national average. For example, those rates for two procedures commonly used to treat coronary artery disease — bypass surgery and angioplasty — were well below the national average. The bypass rate was a little more than half that in Modesto, Calif., and the angioplasty rate was less than half that in Bakersfield, Calif.

But women in Seattle and Spokane with early breast cancer were more than twice as likely as those in San Francisco to undergo a mastectomy — another choice would be a lumpectomy plus radiation. And similar patients in Olympia were more than four times as likely as those in San Francisco to get a whole breast removed.

Culture develops

To the authors, this variation signals that patients are not getting something they very much need: information. They believe patients should get standardized information on the pros and cons of treatment options.

Doctors are often biased — not intentionally, but because they've been trained in a particular way in an academic medical center. Then those doctors go on to train others, and ultimately, a culture develops in a region with a particular way of treating a condition.

Without data such as that collected by the Atlas, "this is often invisible to patients ... and even to physicians," Goodman said, even though the care they deliver may be quite different from that delivered by other well-trained physicians.

Without some sort of structure legitimizing the patient's role in decision-making, he said, "the patient's voice and preferences can be completely lost."

Shannon Brownlee, a co-author of the study, said the prevalence of specialized facilities, such as heart-catheterization labs, also appears to push up rates. "Fact is, if you have a lot of supply there, it tends to get used and it affects, in a perverse way, the decision-making process."

As for patients, who often don't have much information on which to base a choice, they defer to doctors, whose preferences end up "winning the day," Brownlee said.

When patients do get more information, they often change their minds, the authors said. Overall, they slightly prefer less-invasive treatment, such as managing a stable heart condition with medication, diet, quitting smoking and exercise.

In a study published earlier this year in the journal Health Affairs, Group Health Cooperative looked at the effect of informational videos aimed at patients with knee or hip arthritis. Rates of replacement surgeries dropped sharply, by 38 and 26 percent, respectively, over six months, along with costs.

Patients, the report said, were more satisfied with the outcomes, no matter which choice they made.

The Dartmouth Atlas authors said that's what they're after: "When done right, shared decision-making results in a better decision: a personalized choice based on the best scientific evidence and the patient's own values."

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com.

On Twitter @costrom.

Information

Dartmouth Atlas Project: dartmouthatlas.org

Improving Patient

Decision-Making report

(Pacific States):

dartmouthatlas.org/pages/

decision_making_series

Group Health decision video: ghinnovates.org/?p=3977


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