For Elective Surgery, "Where You Live is What You Get"
BY LAUREN UZDIENSKI, MARCH 3, 2011
A new report from the Dartmouth Atlas Project - an organization that studies healthcare utilization by geography - found that likelihood of Medicare patients receiving 10 surgical procedures varied by zip code. This suggests that the surgeon is the driver of whether a patient has surgery or not, and the goal of releasing this data, according to the report, is encouraging shared decision-making between physician and patient.
The 10 procedures identified in the report represent just a handful of procedures that are considered "preference sensitive," or elective procedures for conditions that have numerous treatment modalities (e.g., low back pain). Low back pain is one of the orthopedic conditions that made Dartmouth's list; osteoarthritis of the knee or hip is the other.
Among low back pain patients, the study notes, less than 10% of people who visit a doctor for back pain have an identifiable cause. For patients who have persistent pain, treatment options range from Tylenol to acupuncture to surgery, and Dartmouth reports that surgical outcomes are frequently no better than non-surgical outcomes. However, interestingly, the SPORT study from several years ago suggested that patients who chose spine surgery reported greater improvements than those who were just randomized to it, helping to make one of the Atlas Project's key points: that outcomes can correlate to the patient's role in the decision-making process.
Just how frequently is surgery performed for low back pain across the U.S.? About 4.3 times per 1,000 Medicare beneficiaries. Patients in Casper, Wyoming were more likely to get back surgery than anywhere else, with 10.0 procedures per 1,000 Medicare beneficiaries. The lowest rates of surgery were seen in Honolulu, with 1.7 procedures per 1,000 Medicare beneficiaries.
As for knee and hip OA, Dartmouth cites that among a cohort of Canadian patients shown to have severe pain and significant damage to their joint, only 35% definitely or probably wanted surgery. Despite this general reluctance to undergo a total joint replacement, there is a national average of about 8.0 TKAs for every 1,000 Medicare beneficiaries; that number jumps to 13.8 for patients in Lincoln, Nebraska. The TKA rate in Honolulu is only 2.9 procedures for every 1,000 Medicare beneficiaries. In hip, there are about 3.3 THAs for every 1,000 Medicare beneficiaries across the U.S., with the highest rates reported in Sioux City, Iowa (5.3 procedures per 1,000) and the lowest in - you guessed it- Honolulu (1.0 procedure per 1,000). Non-surgical treatment for OA symptoms can include exercise, weight loss and OTC medication. Surgery comes with long periods of immobility and rehab, and it may not relieve pain or make it worse (which happens in about 10% of patients, according to the report.)
The full report from the project is here, and interactive maps showing procedure distribution by geography are here.
