Surgery frequency varies by geographic norms, Dartmouth study finds

If you have early-stage prostate cancer and you live in Kansas City, you’re twice as likely to have surgery as you would be if you lived in Joplin.

In Cape Girardeau, you’d be nearly three times as likely to have surgery.

Where you live, it turns out, can help determine what kind of elective surgery you get, according to a study released Wednesday by Dartmouth College’s Institute for Health Policy and Clinical Practice.

Why does location matter?

The study, which followed similar research and focused on Midwestern states, suggests that patients do not fully understand their medical options and let their doctors make decisions for them. And community norms judging proper treatment can vary widely in different areas.

“Many patients aren’t even aware that the choice about elective surgery is theirs to make,” said Shannon Brownlee, the lead author of the study and an instructor at the Dartmouth Institute for Health Policy & Clinical Practice.

Informed patients would be likely to have differing preferences for or against surgery, she said.

“But their preferences are often not taken into account,” Brownlee said. “It’s often the physician’s preference that wins the day.”

So, for example, a woman older than 65 who lives in St. Louis would be twice as likely to undergo a mastectomy for full-stage breast cancer as a woman in Peoria, Ill. A patient in Wichita is more likely to undergo elective back surgery than someone in Topeka.

“Where you receive your care has powerful effects on the style of care you receive and decisions that are made,” said David Goodman, co-author and co-principal investigator for the Dartmouth Atlas Project and director of the Center for Health Policy Research at Dartmouth.

Populations differ, and health care needs for those areas will also vary, Goodman said. But that only explains a small amount of differences in elective surgery rates, he said.

The variances, Goodman said, have more to do with how physicians are trained at different institutions. Over time, he said, communities will also develop their own patterns of practicing medicine “that are invisible to them and their patients but have profound effects.”

“Different doctors,” Goodman said, “interpret what’s right for patients differently.”

That leads to “well-meaning doctors who assume they know what’s best for patients” making a recommendation that a patient might disagree with if “they were fully brought into the decision-making process.”

The numbers don’t appear to correlate to the number of specialists in a community, Goodman said. For instance, a large number of orthopedic surgeons would not necessarily translate into a higher rate of hip and knee replacements.

Brownlee said doctors should move toward a model where patients receive a better presentation of the risk and benefits of choosing a more conservative treatment option. That should be done in a way that allows decisions to be made “outside the pressure cooker of a physician’s office, where time is so precious.”

“Decisions around elective procedures should be made with patients,” she said, “not for them.”

When patients are fully involved in the decision-making process, Goodman said, they generally prefer less aggressive treatment.

“With shared decision making, there still would be variation in the rates (of elective surgery),” Goodman said. “But any variations would then reflect patient preferences.”

The project used Medicare data from 2008 to 2010 to look at rates of 10 elective surgeries, ranging from mastectomies to gallbladder removal, and the PSA screening test for prostate cancer.

Similar findings have been reported in other states and regions in previous published studies by Dartmouth.