Whether patients undergo a particular elective surgery may depend on where they live, according to a new report released by the Dartmouth Institute for Health Policy and Clinical Practice, which evaluated Medicare data in the West South Central region.
The report compares variances in the utilization of several procedures.
For example, according to the report, if a patient with heart disease lives in Tyler, he or she is half as likely to receive a balloon angioplasty than if they live in Oklahoma City.
However, a Tylerite is twice as likely to have back surgery than if they lived in New Orleans.
The report emphasizes the importance of choice in health care, the authors said. Shannon Brownlee, lead author and instructor at the Dartmouth Institute for Health Policy and Clinical Practice, said when a treatment is elective, or what they call preference sensitive, there is no one right treatment for that condition.
Each option involves different tradeoffs with different possible benefits and risks. She said various patients are going to view those tradeoffs differently, hence the importance of having the patient involved in decision making.
“We want to highlight its major causes,” Ms. Brownlee said during a teleconference Wednesday. “One of those causes is the fact that physicians vary in their opinions about the best way to treat the same condition. And two, patients have different preferences about which treatment they would prefer if they were really informed about their options. But their preferences are often not taken into account. In other words, it’s often the physician’s preference, the physician’s opinion that ends up winning the day.”
“This report is intended to encourage patients to understand that A, they have a choice and B, that they need to be fully informed about the options they face and share these important health decisions with their team,” Ms. Brownlee said.
“Studies show that many patients are not aware there is a choice and that it’s theirs to make with their physician or other clinicians. Instead, patients often routinely delegate these important decisions to their physicians. They think ‘doctor must know best.’ The doctor is incredibly well-trained, but their physician is not that well trained in figuring out what their patients really care about,” she said. “The result is often that their patient does not get the treatment they would have preferred if they were A, well informed, and B, given an opportunity to choose.”
Ms. Brownlee also said previous data suggests that patients would opt for less invasive or less aggressive treatments if they are well-informed of the risks and benefits of all treatments.
Dr. David Goodman, co-principal investigator, professor of pediatrics and director of Center for Health Policy Research at Dartmouth, said geography is too often a destiny in health care.
He said he understood health care needs vary across the country but it still doesn’t explain the variances. In addition, there is no issue of insurance or access to care since patients reviewed have Medicare.
Goodman said the variation reflects local styles of care and happens because physicians are trained differently in the use of certain procedures.
“We as doctors are trained to judge what patients need and want and to make recommendations,” he said. “Unfortunately, this diagnosis of patient preferences is often flawed. Well-meaning doctors, assume they know what’s best for patients in making recommendations or ordering their recommendations.”
Among the elective surgeries explored in the report is prostate screening. Longview and Athens has a higher percent of male Medicare beneficiaries between 68 and 74 receiving PSA tests, compared to other East Texas cities and the U.S. rate.
The utilization of back surgery is a hot button issue, with “considerable disagreement” within the medical community, Goodman said.
In Tyler, back surgery is conducted on 7 patients per 1,000 Medicare beneficiaries, compared to 4.7 across the nation. It’s higher in Jacksonville, Longview and Gilmer, at 7.3, 7.4 and 8.2, per 1,000 Medicare beneficiaries, respectively.
Goodman said the effectiveness of back surgery is marginal, but alternatives are available.
“Obviously, back surgery or not having back surgery has its own tradeoffs,” he said. “With no consensus, in terms of what is the right procedure, the rate of back surgery reflects local practice styles and this varies from place to place.”
A patient is informed about a surgical or medical procedure or participation in a clinical study after reviewing the risks involved. But Goodman said doctors need to go further than informed consent by making patients part of the decision-making process.
“Informed consent is a legal concept and one that is far distant from the one of decision making,” he said.