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Elective Surgery? Whether or Not you go Under the Knife Depends on Where You Live


The term “elective surgery” pretty much says it all. It’s a surgery that could be part of one’s treatment plan, but is not the only option. A new report from the Dartmouth Atlas Project found huge variations in the rates of Medicare patients undergoing elective surgeries in different parts of the country.

“For bypass surgery for Pittsburgh, it’s 3.6 per thousand, and that’s about the average for the United States. For angioplasty the Pittsburgh is 9.2 per thousand and the U.S. rate is 7.5, so there’s a higher rate there,” said Shannon Brownlee, lead author on the report and instructor at the Dartmouth Institute for Health Policy and Clinical Practice.

"What we think is going on is that physicians differ in the way they treat similar patients..." -Shannon Brownlee

The report highlights the mid-Atlantic region (New Jersey, New York, and Pennsylvania) and shows variations across the region, state, and nation. For instance, if you live in York, PA, you are half as likely to undergo back surgery as those who live in Philadelphia. If you have osteoarthritis of the knee and live in Camp Hill, PA, you are three times more likely to have your knee replaced than if you live in Brooklyn, NY.

“What we think is going on is that physicians differ in the way they treat similar patients, so the physicians in one community think the best way to treat knee pain is helping patients with physical therapy and pain meds, whereas another group of physicians might instantly recommend surgery,” said Brownlee.

She uses breast cancer as an example. There are two surgical options for women: a mastectomy, where the whole breast is removed, or a lumpectomy plus radiation.

“Those two choices have really different impacts on women and different women are going to choose one over the other. If you choose mastectomy, you don’t have to worry so much about a local recurrence of your cancer and you don’t have to go through radiation treatment, but you lose a breast,” said Brownlee, “if you have a lumpectomy, you have to go through radiation and you have a much higher chance of having to have more surgery, or you have a local recurrence.”

She said the two are equivalent in fighting breast cancer, but have very different outcomes, so a breast cancer patient would have to know the outcomes of each and take into account what they value, and which option is best for them. In many cases women jump to mastectomy because they feel it will be the most effective option, not realizing they have other options.

Communication is key

This is a problem, added Brownlee, because somewhere along the healthcare chain, patients aren’t getting all of the information they need to make decisions about their own care.

“There’s a breakdown in communication,” she said, “we know from all kinds of studies that many patients don’t even know they have a choice, that there are multiple ways to treat many conditions.”

Brownlee said patients can take matters into their own hands. One step they can take is requesting something called a patient decision aid. That can take the form of a pamphlet, video, online posting, but they help patients understand that they have a choice in the elective surgeries, understand what the pros and cons are about each choice, and it allows them to think of their own values in decision making.

“There’s a very interesting movement happening in medicine right now where more and more physicians are embracing this idea of shared decision making and there’s a real need for more really balanced, really good patient decision aids,” she said.

Who makes the final decision?

In many of the cases, the preferences of the patients doesn’t come up, and if a doctor even suggests surgery, patients oftentimes take that as meaning they absolutely need it. One of the hopes with reports such as this is that it will not only empower patients, but also help physicians understand where improvement is needed.

“When these reports come out physicians say, ‘wow! Who knew we were so high, or so low?’ And they start to look at their own practices and say ‘what is it we are doing that leads us to have such a high rate or such a low rate?’”

Brownlee said there are three major hopes for the report:

  • That it will alert clinicians to start thinking about how well they are accomplishing the goal of really informing their patients and really inviting patients into conversations on these crucial issues of “should I have the surgery?” and “Which surgery should I have?
  • That patients will say, “wait a minute, I’m not being very well informed, I need to be better informed,” and take action to better understand their options.
  • That legislatures will take a look and consider laws that require physicians to better inform their patients either through patient decision aids or other means.

“There is now real movement afoot in a number of states, Washington state is leading the way, the legislature there, about five years ago, passed a bill that mandated a demonstration of the use of patient decision aids, and lawmakers gave physicians who engaged in shared decision making a little bit of extra legal protection from lawsuits,” said Brownlee.
This report is one in a series of nine that analyze care in regions across the US. Specifically, researchers looked at how Medicare patients in different regions differed in elective treatments from 2008 to 2010. Elective procedures include: mastectomy for breast cancer, coronary artery bypass surgery, percutaneous coronary intervention, back surgery, knee replacement, hip replacement, prostate cancer screening, and radical prostatectomy for prostate cancer.