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Location Drives Medical Decisions

Dartmouth Study: Where You Live Is What You Get

Lebanon — Thinking about surgery to cure pain in your lower back? Wondering whether you should get a total knee replacement? The answer may depend on where you live.

Dartmouth researchers said Thursday that decisions on many types of elective surgery vary widely from region to region, and also across the nation.

The reasons have less to do with demographic differences or even the severity of a patient’s condition, according to the researchers. Rather, what matters is how well doctors explain options to patients and then include them in making a final decision on surgery.

“It’s really where you live is what you get,” said Shannon Brownlee, lead author on a series of reports released last week and an instructor at The Dartmouth Institute for Health Policy & Clinical Practice.

Looking at Medicare beneficiaries over the age of 65, Brownlee and a team of researchers discovered wide variations in how likely patients were to choose certain types of surgery to treat a condition. In New England, for example, residents in Hartford, Conn., are three times as likely to get a mastectomy to treat breast cancer than people who live in Lebanon. And in treating lower back pain, patients in St. Albans, Vt., are five times as likely as Morrisville, Vt., residents to choose back surgery.

The findings suggest that there are stark differences among regions and individual institutions in how doctors involve patients, and should serve as a lesson not only to providers, but also to patients in the role they play in determining their care. “The report is intended to encourage patients and their families to understand first that they have a choice when it comes to many, many treatment decisions,” Brownlee said in a conference call with reporters. “And that they need to understand those choices and they need to share those decisions with their health care team.”

Elective surgery refers to procedures that are scheduled in advance because a person’s condition is non-life threatening. All too often, patients aren’t given the opportunity to choose whether to have a procedure done because they are not involved in making the decision, the report said. Instead, they defer to the doctor, who may not have any understanding of what the patient really wants.

There are often multiple ways to treat a condition. Weighing the pros and cons of different approaches is important to make sure patients don’t go into surgery with unrealistic expectations, Brownlee said.

For example, women with early stage breast cancer can choose between a mastectomy, in which the entire breast is removed, or a lumpectomy, which removes the tumor and a bit of surrounding tissue while preserving the breast. Typically, women who choose a lumpectomy also receive radiation therapy. The two approaches are equally effective in reducing the chances of dying of breast cancer. Therefore, decisions on what to do must be made with the patient’s priorities in mind. If she is uncomfortable having radiation treatment, then a mastectomy might be a better decision.

High or low rates of treatment are not necessarily an indicator of “good” versus “bad” care, said David Goodman, a professor at Dartmouth’s Geisel School of Medicine who worked on the study. There’s no way of knowing the “perfect rate” for a community. But when patients are well-informed, they typically choose less-aggressive options.

By this measure, Upper Valley residents would seem to be well-informed. The rates of elective surgery were generally lower than national and regional averages, according to the study. In Lebanon, for example, patients were less likely than residents in other parts of the nation to seek back surgery, get a knee replacement or have their gallbladder removed. It was the same for people in the areas surrounding Claremont, New London, Randolph and Woodsville, all communities with hospitals.

The rate of hip replacements, however, was slightly higher in all of those communities except for Claremont.

Dartmouth-Hitchcock has long promoted a model of including patients in decisions about their care.

In 1999, it established the first center in the United States dedicated to encouraging doctors and patients to make decisions together. Located between the information desk and the food court at Dartmouth-Hitchcock Medical Center, the center includes a library of “decision aids,” or DVDs, booklets and other materials used to help teach patients about the options available to them. There are also web-based videos patients can watch.

The materials are produced by non-profit organizations with no ties to insurers or medical device manufacturers who might have financial incentives to influence patients, said Susan Berg, the center’s interim program director.

“The purpose of a decision aid is to provide information in understandable ways about what the options are,” she said. “It’s to help them prepare to have a conversation with their physician.”

The center also offers one-on-one counseling for patients who want to talk with someone.

Berg said she’s met with around 60 to 70 people and sent 4,000 decision aids to patients over the past year.

Berg said her role is not to offer advice or tell patients what they should do, even if they ask. Rather, she’s there to help them figure out their concerns and goals for recovery.

Not every hospital has the resources to have a library of decision aids or hire someone like Berg on staff. This leaves the responsibility to nurses and physicians to make sure the patient is well-informed.

Oliver Herfort, chief medical officer at Valley Regional Hospital in Claremont, said he simply lays out options for his patients and tries to have honest discussions with them, not only their condition but their life circumstances. This involves frank conversations about a person’s age, the benefits of a particular test and even personal finances. “Economics, especially in Claremont, this is a major deciding factor with a goal of delivering high value care,” he said.

There’s no special training that Valley Regional provides physicians to help them communicate better with patients. However, medical schools are beginning to include shared-decision making strategies in their curriculum. The Geisel School of Medicine is among those institutions, Goodman said. The accreditation institutions that set standards for physician training must also incorporate some of these principles for involving patients in decisions about their care, Goodman said. Changing institutional culture won’t come easy, he said, as the ways that hospitals or physician practices approach patient care “are remarkably durable over time,” he said.

Just because a patient is well-informed doesn’t mean he or she will always opt out of surgery, he said. But it will lead to better decisions about care.

“Patients don’t always choose a less aggressive treatment,” he said. “Sometimes patients end up choosing a more aggressive treatment than they would if they hadn’t been part of shared-decision making. … But what’s more important is that individual patients choose the treatment that’s right for them.”

Chris Fleisher can be reached at 603-727-3229 or cfleisher@vnews.com.