Thursday, December 14, 2017
Health

With elective surgery, where you live is what you get, says new study

Whether Medicare patients undergo elective surgeries has a lot to do with where they live, according to a study released this week.

Seniors with heart disease are half as likely to undergo balloon angioplasty if they live in Savannah, Ga., than if they live in Gainesville. Patients are nearly three times more likely to get their knees replaced if they live in Roanoke Rapids, N.C., than if they live in Miami Beach.

The findings led researchers at the Dartmouth Institute for Health Policy & Clinical Practice to come to this conclusion: Patients are letting their doctors, who are entrenched in the local medical culture, make decisions for them.

"Many patients aren't even aware that the choice about elective surgery is theirs to make," said lead author Shannon Brownlee. "The result is that patients don't really get the treatment they prefer."

The report by the group, which is affiliated with Dartmouth College in New Hampshire, is part of its well-known Dartmouth Atlas Project, which tracks health care trends and has reported on wide geographic variations in Medicare spending for more than 20 years.

Last year the project released a report that found differences in elective surgery rates among the regions of the country. The latest report examines variations between 2008 and 2010 within the regions, even within the states.

Researchers studied more than 500 hospital markets (geographic areas served by a small number of hospitals) in the South Atlantic region. The treatment included 10 elective surgeries — including hip replacements, mastectomies and gallbladder removal — and the PSA screening test for prostate cancer.

The report divided the Tampa Bay market into four regions with referral hospitals: Clearwater, Hudson, St. Petersburg and Tampa. Drawing conclusions about any particular hospital's practice is difficult, however, because the rates track where people live, not where they get their procedures.

So a Medicare beneficiary who lives in Clearwater but got treatment in Tampa would be counted as a Clearwater patient, not a Tampa patient.

There were some rates that stood out. In Hudson, where Regional Medical Center Bayonet Point is located, a higher rate of Medicare patients underwent balloon angioplasty in 2010 (10.3 patients per 1,000 Medicare beneficiaries) than did those in Tampa (7.1). The national rate was 7.5.

Hudson also had the highest rate (5.4) of surgery to remove the gallbladder due to gallstones, or cholecystectomy. The national rate was 3.3.

Bayonet Point spokesman Kurt Conover said the hospital hadn't seen a spike in cholecystectomies. He said a number of patients seen by primary care doctors at Bayonet Point end up going elsewhere for the procedure.

In a telephone call with reporters this week, researchers said they aren't saying the rates should necessarily be lower in any one community. But they said the variation in the rates suggests many patients aren't fully informed of all their options and might have chosen more conservative treatment.

When it comes to the quality and consistency of the information patients get, said author David Goodman, "it's a dismal picture out there."

The researchers had no clear answers about why one medical community might be more likely than another to push a certain elective procedure. Goodman said the rates didn't appear to be tied to the number of specialists in a community. For instance, a large number of orthopedic surgeons would not necessarily translate into a higher rate of hip and knee replacements, he said.

Goodman suggested the answer lies more in each community's "well-established patterns of practicing medicine." These cultures, he said, "are remarkably durable over time."

"It's very much an example that, at least to date, geography is destiny."

Researchers say they hope the lesson for both patients and their doctors is to move toward a model known as "shared decision-making," in which the patient receives a better presentation of the risk, and benefits, of choosing a more conservative option.

That decision-making might involve information packets that the patient can review at home and not the "pressure cooker" of the exam room, said Goodman.

The trick, they said, will be to developed standardized, unbiased presentations. Insurers might want tools that discourage patients from expensive treatment; surgical equipment manufacturers might want to nudge patients toward procedures that would benefit their bottom line.

Jodie Tillman can be reached at [email protected] or (813) 226-3374.

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