Geography determines who gets surgery, study finds

Where you live could be a powerful determinant of what kind of elective surgery you get, even within a state or city, said a study released Thursday. The authors of the Dartmouth Atlas Project said that could reflect less patient choice and more physician practice tied to local tradition.

The project used Medicare data from 2010, or in some cases averaged data from 2008-10, to look at rates of elective surgeries in the areas hospitals serve. Even within similar states, such as in the South Atlantic region, which stretches from Maryland and Delaware to Florida on the East Coast, rates of some “preference sensitive” surgeries varied widely for similar conditions, said Dr. David Goodman, a co-author and co-principal investigator of the project.

“It is very much an example of where, at least to date, geography is destiny,” he said. “These places really do have their own distinctive signature of surgical practice.”

A Medicare beneficiary in Savannah, Ga., for instance, is twice as likely to receive surgery for lower back pain as a similar patient in Rockville, Md., Goodman said.

The Augusta hospital region usually ranked on the more conservative side in elective surgeries compared with other regions in the South Atlantic. Augusta was near the bottom in rates of hip replacement and surgery to treat early-stage prostate cancer, for instance, but near the top in balloon angioplasty and similar interventions to treat stable angina, the study found.

Rates of other areas of Georgia varied widely, and across the regions studied there was no discernible pattern that would favor rural over urban, or vice versa. Those geographic differences “are really dwarfed by this more idiosyncratic variation that occurs from the local culture of practice” by physicians, Goodman said.

That concerns the group because it might reflect that patients are delegating the choice to have surgery to the physicians, who are usually trained to take a more aggressive approach, Goodman said. That might not reflect what the patient truly wants or needs, study lead author Shannon Brownlee said.

“Patients often don’t get the treatment that is best for them,” she said, “and that’s one of the main things that drive this unwarranted variation.”

The problem stems from a lack of knowledge about the full extent of risks and benefits from the surgery, sometimes on the physician’s part, too, or the inability to communicate that to patients, Goodman said

The Patient Protection and Affordable Care Act will help disseminate a better model of physician-patient interaction, called Shared Decision Making, that seeks to involve patients and families more in the process and give them clearer information on benefits and risks from the procedures. That could bring the rate of some elective surgeries down, Goodman said.

“In general, for many of these procedures in aggregate, the (patients’) choices are to less aggressive care,” he said. “But what is more important is that individual patients choose the treatment that is right for them or the screening test that is right for them.”

Staff Writer Sandy Hodson contributed to this article.

Database of surgery rates

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