Report says surgery choice often depends on geography, including in SD

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Whether patients have elective surgery depends largely on where they live and not necessarily how sick they are, a newly released report says.

“It really reveals some of the most troubling aspects about our health care system,” said David Goodman, a co-principal investigator for the report, during a teleconference Wednesday. “Geography is too often destiny in health care.”

A report from the Dartmouth Atlas Project, based at Dartmouth College, Hanover, N.H., shows the rates at which patients have elective surgeries can vary greatly state by state, and even city by city.

Shannon Brownlee, a senior author of the report, said treatment options, including the need for surgery, are too often dependent “not on how sick (patients) are, not on who they are, but on where they live.”

The report says it hopes to address “the fact that patients’ preferences are not always taken into account when medical decisions are made.”

A regional report released Wednesday shows the rates at which patients have one of 11 elective procedures for eight common conditions in seven states in the Midwest: Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota and South Dakota.

Among those states, the report shows patients in South Dakota were generally less likely to have coronary artery bypass surgery to treat stable angina, or chronic chest pain due to plaque build-up in arteries in the heart. But female patients were generally more likely to have a mastectomy, or the removal of a breast, to treat early-stage breast cancer in South Dakota.

The report determined rates of surgery based on the number of procedures performed on Medicare beneficiaries divided by the total number of Medicare beneficiaries in a given geographic area. Rates were calculated using either numbers from 2010 or three-year averages of the numbers between 2008 and 2010, the report says. The rates were based on where the patient lived, not necessarily where they received treatment.

Even within South Dakota, the rates at which patients undergo elective surgery can vary, the report shows.

For example, Mitchell has the highest rate of any city in South Dakota listed in the report of male patients undergoing surgery to treat enlarged prostates. Mitchell’s rate is nearly five times the rate in Sioux Falls, nearly three times the rates in Huron and Rapid City, and nearly twice the rate in Pierre.

The report shows patients in Mitchell have surgery to treat lower back pain at a similar rate to those in Sioux Falls and Rapid City, but patients in Winner are about 43 percent less likely to have the surgery than patients in those cities, while patients in Tyndall are about 60 percent more likely to have it.

The rate of knee replacements in Mitchell is about 10 percent higher than in Sioux Falls, the report shows, but about 30 percent lower than in Wagner and Parkston, and about 55 percent lower than in Platte, which had the highest rate of any city in South Dakota listed in the report.

The report shows the rate of hip replacements was relatively consistent across most of the cities in South Dakota listed in the report.

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

The source of some of the variation can be found in the different training programs that physicians and surgeons attend in different areas, he added.

There are “quite striking differences” within both urban and rural settings, Goodman said.

Brownlee encourages patients to become informed and to take part in the decision-making process with their doctors.

“When patients don’t get a chance to be really informed and make a choice, the physician is at risk of prescribing the wrong treatment for the wrong patient,” Brownlee said.

When patients become more involved, both doctors and patients will benefit, the reports says.

“When done right, shared decision-making results in a better decision: a personalized choice based on both the best scientific evidence and the patient’s own values.”

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