Where you live is what you get. Research has shown that the use of many elective tests and procedures, including surgery, is often be based more on the where the patient lives rather than the treatment the patient needs or prefers. For example, cardiac patients living in Clearlake, California are up to 10 times more likely to undergo elective invasive cardiac procedures than similar patients in the Sonoma, California area.

While the reasons behind such variation are hotly debated, a new report from the New America Foundation, the California Healthcare Foundation and Stanford University supports the idea that physicians' opinions can dictate many of these decisions -- potentially putting patients at unnecessary risk of getting a treatment they would not have wanted had they been more involved in the decision.

Shannon Brownlee, MS, New America Foundation Health Policy Program, comments, “When it comes to elective procedures, there’s no right answer, no best treatment. Most patients want to be involved in such decisions, and to understand their treatment options, which can have a huge impact on their lives. All too often, the provider’s preference is the deciding factor.”     
             
In an analysis of California state data, reports by Brownlee, Stanford University researcher Lawrence Baker, PhD, and Vanessa Hurley, MPH, of the New America Foundation Health Policy Program documented and analyzed geographic differences in the following reports.                     

• Seven in-depth "Close-Ups" provide data on 13 specific procedures, including hip and knee replacement, coronary artery bypass graft surgery, angioplasty, elective induction of childbirth, and weight loss surgery.
• An interactive map presents easy access to data on these procedures throughout California.
• A background report, "All Over the Map: Elective Procedure Rates in California Vary Widely," discusses the factors involved in variation and highlights the important role that patient input can play in decisions about treatment options.                             

Only elective procedures were included in the research because the rate at which they are delivered is determined by the preferences of clinicians and patients. Procedures were chosen because they are commonly performed and/or because earlier studies have shown wide geographic variation in their rates elsewhere.
                           
Though earlier studies on geographic variation have focused primarily on Medicare patients, this analysis examines the Medicare population (both fee-for-service and managed care), as well as younger individuals enrolled in commercial plans or Medicaid or who are uninsured. The consistency of results across the over- and under-65 population makes this a significant contribution to the literature documenting geographic variation.                            

Examples from the findings:                            

• Marysville region residents have coronary artery bypass graft surgery at 264% of the average rate for the state for California.                          
• Red Bluff region residents undergo knee replacements at 200% of the state average rate.    
• Women who live in the Berkeley region deliver vaginally after having had a cesarean section at 301% of the state average rate.                          
• Ridgecrest residents (in the San Bernardino area) have gall bladder surgery at 177% of the state average rate.                            
• Residents over age 65 in seven of San Diego's Hospital Service Areas undergo elective angioplasty at least 150% the state average rate; in the Brawley region, for example, these residents undergo elective angioplasty at 211% of the state average.                  

While some geographic variation in rates of procedures is expected due to differences in the prevalence of disease, note the authors, much of the variation seen across California cannot be explained by illness rates. Some communities in California were found to have procedure rates that were 150% of the state average while others were as high as 550% -- far exceeding differences in health status. Other communities have exceptionally low rates. The analysis by Baker controlled for age, sex, race, education, income, and insurance status; in the case of heart procedures the analysis also took into account rates of heart attack and diabetes, which reflect the prevalence of heart disease.
                       
The authors note that for elective procedures, a patient's own values and willingness to accept uncertainty in outcomes should be considered alongside the clinician's recommendations. They state one way to encourage that communication is through shared decisionmaking, a formal process intended to ensure that patients are fully informed about their options.  

To view the accompanying report on shared decision making, go here:

http://newamerica.net/publications/policy/patient_decision_aids_and_shar...