All too often, patients facing elective surgeries are not given the chance to learn about the full range of options available to them. Many go into the operating room unaware of the unique risks and benefits of the procedure they're about to undergo. Some even fail to understand the elective nature of the treatment, that the decision to go under the knife is actually theirs -- and not their doctor's -- to make. The result? Patients often don’t get the treatment they would have preferred had they been if fully empowered and informed.
Today marks the unveiling of a new report from the Dartmouth Atlas Project and the Foundation for Informed Medical Decision Making that illuminates this enormous problem. And it is enormous. As many as 70 percent of patients undergoing certain surgical procedures would have chosen a different option had they had a chance to be fully informed, and to share the decision with their provider.
For Medicare patients with conditions that can be treated with surgery, whether or not they undergo elective surgeries depends largely on where they live and the clinicians they see. According to the report:
Researchers found Medicare patients living in Casper, Wyoming are nearly six times more likely to undergo back surgery than patients living in the Bronx. Medicare patients with heart disease in Elyria, Ohio, were 10 times more likely to have a procedure such as angioplasty or stents than those in Honolulu. And women over 65 living in Victoria, Texas were seven times more likely to undergo mastectomy for early-stage breast cancer than women in Muncie, Indiana.
(Full report available here)
To highlight the dramatic findings of this study, the New America Foundation will host a roll-out event at 3:00pm on Friday, February 25th. (Register here) Shannon Brownlee, the lead author of the study and Acting Director of New America’s Health Policy Program will open with a short presentation of the Atlas’ findings, followed by remarks from Len Nichols, the Director of the Center for Health Policy Research and Ethics at George Mason and Christine Bechtel, Vice President of the National Partnership for Women and Families.
The report used Minnesota as a case study to highlight that even in a state widely known as a leader in patient-doctor collaboration, there remains room for significant improvement.
Variations of this magnitude are the byproduct of a system in which physicians and patients are often unequal partners in the decision making process. What patients truly want may not be taken into account when medical decisions are made. In addition to analyzing data on practice patterns, the report advocates for shared decision making, a process by which a patient is fully informed about the potential risks and benefits of available procedures before choosing a treatment plan with their doctor.
In the absence of clear, evidence-based guidelines for care, rates of surgery can vary wildly based on non-medical criteria. Rates in small communities, for example, can swing based on the opinions of one practice or a small number of doctors. Some prefer surgery, while others might be motivated by lucrative reimbursements for the procedures. "The goal really is to get patients and others to see the extraordinary range of the variation," said Shannon Brownlee to the Star Tribune. "While some differences are to be expected, she said, "those differences are swamped in many cases by the variation that is driven by [a doctor's] opinion."
The release of this newest Atlas will advance the conversation about appropriate rates of medical care and about truly patient centered care. We've been making the case that overtreatment is rampant in our health system, from implanted defibrillators to early induced delivery to mammography. We simply don't know what the "right" rates are, but we know that when patients are fully informed, they may want less care, or less invasive care. According to Dr. Michael Barry, President of the Foundation for Informed Medical Decision Making, a patient engaged in shared decision making chooses a more conservative course of treatment for a variety of conditions on average 20 percent more often. With the health system's current cost crisis, supporting conservative -- often less expensive-- treatment is an essential tool to lowering utilization and controlling runaway health expenditures. Doing so with shared decision making can tackle this problem WHILE improving patient outcomes and satisfaction. It beats the alternative of waiting until impending fiscal catastrophe forces more draconian decisions.
But the more important reason to advance shared decision making is that it's the right thing to do for patients. We hope you can join us in bringing attention to this critical issue.