Last week, the Dartmouth Atlas published a new set of data reviewing variations in the rate of usage of "preference-centered care.” The discussion of the data is called “Where you live is what you get”. This finding has been consistent since the 1970s, when Jack Wennberg first studied tonsillectomy rates in neighboring small communities in Morrisville and Waterbury, Vermont.
In Waterbury, the tonsillectomy rate by age 15 was 20 percent, and in Morrisville the rate was 60 percent. When the Morrisville physicians were presented with the data on variation, the rate of tonsillectomy dropped to 10 percent over two years.
Sadly, over 40 years later these dramatic variations in rates of procedures persist. For example, rates of mastectomy varied more than fivefold in New England, ranging from a low of 0.3 per 1,000 female Medicare beneficiaries in Springfield, Mass., to 1.5 per 1,000 in Hyannis, Mass.
These data are derived from Medicare beneficiaries who received care between 2008 and 2010. What is strikingly useful about this record is that the Dartmouth Atlas researchers have parsed the data not only into the 366 hospital referral regions in the country (populations surrounding tertiary care centers), but also at the level of the individual hospital: 3,400 individual hospitals. The website is rich in data for comparing individual hospitals’ medical staff rates of elective surgical procedures. The Dartmouth researchers referred to the elective procedures reviewed as "preference-centered care.”
The example of mastectomy for early-stage breast cancer is instructive. The surgical choices women face are mastectomy or lumpectomy. In the words of the researchers,"Clinical trials have shown that the two treatments are the same in terms of a woman’s chances of surviving her cancer, but they are obviously very different in terms of their effect on her body and possibly her sense of well-being. Different women will prefer one option or the other, depending upon how much they value preserving their breast, their willingness to undergo radiation or more invasive surgery, and the level of uncertainty they are willing to live with in terms of their cancer recurring.”
What is troubling about this data about variation is that there is good evidence that patients are making decisions about these elective surgeries without adequately understanding their options. Thus the clinician’s preferences and beliefs are more likely to drive the decision and create this level of variation.
Enter “shared decision-making aids.” Internet-based interactive systems, DVDs, or brochures, these aids have emerged from the awareness of variation and the need for patients to fully understand their options and how they fit into the individual’s values and lifestyle. A new ethical standard is being set by recommendations from professional societies and the American Medical Association to make such tools available to patients. Seven randomized clinical trials have now shown that surgery rates decline when these tools are used, with no evidence of harm from not performing surgery.
Interestingly, I looked up surgical rates for Cooley Dickinson Hospital. It appears we are reasonably parsimonious with surgery; across these procedures we are significantly below national rates, close to Boston rates, and much lower than southern Connecticut rates. As we migrate into a world where elective surgeries become costs to Accountable Care Organizations, we are well positioned. By adding formal shared decision making for our patients we can probably refine to be more aligned with patient values, and probably save a bit of the expense traditionally associated with surgery.