Putting Surgery on the Map
What is most likely to determine whether you have surgery?
Geography, believe it or not.
Doctors do lots of coronary bypass surgery in Alabama, Arkansas and Michigan.
Mastectomy rates are highest in the Midwest.
Knee replacement surgery is very popular in the upper Midwest and the Rocky Mountain region.
And back surgery is a booming business in California, the Northwest and the Rocky Mountain area, along with the Carolinas and parts of Florida and Texas.
An enduring mystery of medicine--why rates vary so much--is dramatically illustrated by the new Dartmouth Atlas of Health Care, a massive study of hospital spending and surgery among the nation’s Medicare population.
“The amount of care consumed by Americans is highly dependent on where they live--on the capacity of the health care system where they live, and on the practice styles of local physicians,” the Atlas reported.
The Atlas’ message is also that medicine is as much an art as a science, an art that demands aggressive and informed patients joining doctors in the decision-making process.
Where the science is clear, the treatments don’t vary. A hip fracture can be treated only with hospitalization. But many other conditions are “high variation.” In their use of surgical remedies doctors--and their patients-- have so many choices.
A woman with breast cancer, for example, can have a mastectomy or a lumpectomy. A man with prostate cancer can undergo surgery for complete removal of the prostate, or can opt for “watchful waiting” for this slow-growing cancer.
A person who has coronary artery disease, which brings chest pain or shortness of breath, can choose a bypass graft to relieve the symptoms. Or doctor and patient may agree that a change in diet, some exercise and medicines are sufficient to deal with the problem.
Instead of a national system of health care, with scientific standards for surgery, there is a hodgepodge of markets.
More hospital beds, more surgeons and specialists in the community mean more surgery. Some medical schools train their graduates to be more aggressive in recommending and performing surgeries. Some hospitals have influential chiefs of staffs, revered and respected by younger doctors, who are strong advocates of surgery. All these answers are guesses, incomplete explanations for the mystery.
Even within a single state, the regional variations are a puzzlement. Nobody knows why the rate of coronary bypass surgery is 45 for every 10,000 Medicare enrollees in Orange County, 47 in Santa Barbara, and 51 in Los Angeles. The gap is huge between Sacramento, with a rate of 62, and San Francisco, with just 43.
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Nobody knows what the rate of surgery should be. “There is no right treatment for a population--no single correct rate of surgery-- any more than there is a right number of pairs of shoes for the American public to own,” said Dr. John E. Wennberg of the Dartmouth Medical School, who directed the Atlas project.
Medicare data was used because the massive government health program gathers detailed information from doctors and hospitals on every hospital visit by a Medicare enrollee. There are standard reporting forms, unlike the disparate information systems used by insurance companies and health maintenance organizations serving the under-65 population.
But experts believe the great variations in surgical treatments also exist for the general population, in addition to the 38 million Medicare beneficiaries (those older than 65 and the disabled of all ages).
“What rate [of surgery] is right for you?” was the rhetorical question from Dr. Jonathan T. Lord, chief operating officer of the American Hospital Assn., which issued the Atlas in cooperation with Dartmouth’s Center for the Evaluative Clinical Sciences.
“For each of us, [the degree of] fear and concern . . . will be different,” he said. “What is the evidence [that] surgery produces beneficial outcomes? That it extends life?” For most procedures, there is no hard evidence that surgery is superior to other methods of treatment.
With managed-care pressures to hold down costs, especially in California, surgical rates will drop quickly in coming years, predicts Dr. Jack Lewin, chief executive officer of the California Medical Assn.
“There will be fewer elective procedures,” Lewin said. “We will say to people, ‘You can make it with physical therapy and exercise rather than having the knee replaced.’ On back surgery, we will use exercise or yoga or other things,” he said.
The country needs “quality of life studies,” which follow patients for years after their medical and surgical treatments, he said. “We may be doing surgery when less invasive procedures work just as well.”
Meanwhile, without the scientific basis, the decisions are made on other grounds, such as community pressures and preferences.
“If you live in Beverly Hills, a woman aged 50 may be preparing routinely for her second face lift,” Lewin said. There is a high concentration of plastic surgeons in the area and “a community expectation that one is supposed to have a face lift at age 50,” he said.
Bend, Ore., has one of the highest rates of back surgery in the country, according to Dr. Bruce Spurlock of the California Healthcare Assn. “What is different about Bend?” he wondered. “Did the bad backs draw all the surgeons there, or were the surgeons aggressive in terms of treating back pain with surgery?”
Within the healing professions there is “broad uncertainty about the appropriate care of back pain,” he noted.
In Bend, back surgery is performed on 76 of 10,000 Medicare enrollees, a surprisingly high figure compared with the U.S. average of 29. (California figures include 28 for San Francisco, 30 for Sacramento, and 32 each for Los Angeles and Orange counties.)
The Dartmouth Atlas “raises more questions than it answers,” by displaying the sharp variations that cry out for a rational explanation that isn’t there, said Spurlock.
One might expect consistency within a single health organization, but even here, the mysteries abound. Spurlock works in the Kaiser Permanente system, where Sacramento members have a rate of coronary bypass surgeries three or four times greater than members in Oakland.
“We don’t have a good understanding” of the causes of the variations, he admitted.
The Atlas patterns of variation aren’t limited to the volumes of individual types of surgery. Spending in the last six months of life also varies without coherent explanation. Medicare outlays were as high as $14,212 in Miami, and as low as $6,793 in Portland, Ore.
Geography also determines the likelihood of spending time in an intensive care unit in the last six months of life. The chances are greatest for those who live in Los Angeles, Chicago and Houston, and lowest for residents of Milwaukee, Seattle and Minneapolis.
The Dartmouth Atlas, helped by a grant from the Robert Wood Johnson Foundation, should be more than a guide to medical mysteries. Instead, it should “help people become better health managers,” said Lord of the American Hospital Assn. Patients should be at least as aggressive as surgeons, asking the doctor if the operation is a necessity, or whether other treatments can do just as well.
