Elective Surgery in the United States: Location Matters

    • December 13, 2012

Lebanon, N.H.—Medicine involves decisions. But for Medicare patients with conditions for which surgery is an option, whether they undergo elective surgery depends largely on where they live and the clinicians they see, according to new research from the Dartmouth Atlas Project.

Research suggests that for many conditions—especially those that can be treated with elective surgery—the treatment a patient receives depends more on the physician’s recommendations than the patient’s preferences. When studying elective procedures across the nation, researchers found remarkable variation in these surgeries for Medicare patients, even though they had similar conditions.

Dartmouth researchers have released a series of nine regional reports that show variations in elective procedures across the country. For example, Medicare patients in Casper, Wyo., were nearly seven times more likely to undergo back surgery than patients in Honolulu, Hawaii, and women over 65 in Grand Forks, N.D., were seven times more likely to have a mastectomy for early-stage breast cancer than women in San Francisco. In Miami, nearly 60 percent of men age 68 to 74 received a PSA test, making them 15 times more likely to be screened than in Lebanon, N.H., where less than 4 percent of men had a PSA test.

“Decisions around elective procedures should be made with patients, not for them. But all too often, what the patient might prefer doesn’t even come up, and it’s the clinician’s opinion and personal beliefs that determine the course of treatment. This report is intended to alert health care professionals to this problem, and to let patients and their families know they have choices,” said Shannon Brownlee, MS, lead report author and instructor at the Dartmouth Institute for Health Policy & Clinical Practice.

Previous research has shown that patients are routinely in the dark that the decision about elective surgery is actually a choice and that it should generally be theirs to make. The result is that patients often do not get the treatment that they would prefer.

“Traditionally, patients rely on their physicians to make health care recommendations in their best interest. But for some of the most important decisions, the best choice can’t be anticipated by doctors—it depends on the patient’s preferences,” said David C. Goodman, MD, MS, 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 & Clinical Practice.

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.

“These variations reflect real problems in how medical decisions are made. Elective surgery presents choices that should be based as much on an individual’s preferences and circumstances as the clinician’s judgment and experience,” said John R. Lumpkin, MD, MPH, director of the Health Care Group at the Robert Wood Johnson Foundation, a longtime funder of the Dartmouth Atlas Project.

The report series analyzes care provided in regions across the U.S., specifically focused on trends in elective, or “preference-sensitive,” procedures. Emphasizing the importance of choice in health care, researchers looked at how Medicare patients in these regions differed in receiving elective treatments from 2008 to 2010, including: mastectomy for breast cancer; coronary artery bypass surgery; percutaneous coronary intervention; back surgery; knee replacement; hip replacement; carotid endarterectomy; cholecystectomy; transurethral resection of the prostate; prostate cancer screening; and radical prostatectomy for prostate cancer.

‘‘Patient preference is especially important when facing a decision about a test or treatment where there is more than one medically reasonable option. 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,’’ said Michael J. Barry, MD, report co-author and president of the Informed Medical Decisions Foundation.

The Dartmouth Atlas Project is located at the Dartmouth Institute for Health Policy & Clinical Practice. The Improving Patient Decision-Making in Health Care: A 2012 Dartmouth Atlas Series and region-specific data can be found at www.dartmouthatlas.org/pages/decision_making_series.

Media Contacts:
Eva Fowler | MSL | eva.fowler@mslgroup.com | (202) 261-2868
Annmarie Christensen | Dartmouth | annmarie.christensen@dartmouth.edu | (603) 653-0897


About the Dartmouth Atlas Project
For more than 20 years, the Dartmouth Atlas Project has documented glaring variations in how medical resources are distributed and used in the United States. The project uses Medicare data to provide information and analysis about national, regional, and local markets, as well as hospitals and their affiliated physicians. This research has helped policy-makers, media, health care analysts, and others improve their understanding of our health care system and forms the foundation for many of the ongoing efforts to improve health and health systems across America.

About The Robert Wood Johnson Foundation
The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to health and health care, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, measurable, and timely change. For 40 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime. For more information, visit www.rwjf.org. Follow the Foundation on Twitter www.rwjf.org/twitter or Facebook www.rwjf.org/facebook.

Media Contacts

Melissa Blair

Robert Wood Johnson Foundation (609) 627-5937