State of Health Blog from KQED News » Geographic Variation

Where You Live Affects What Kind of Surgery You’ll Have: Look It Up

Lisa Aliferis — Tue, 21 May 2013 11:41:24 +0000

(Getty Images)

Where you live matters. And in health care, it matters in all sorts of ways you might not think of immediately. If you’re having elective surgery, one of the major factors determining what kind of treatment you will receive depends on where you live, according to new research released Tuesday.

In health policy, “elective” does not necessarily mean cosmetic surgery. Treatments for early stage cancers are considered “elective” because there are a range of options. The California Healthcare Foundation (CHCF) has been following this issue in its “All Over the Map” project. Previously, the foundation has examined variation in heart procedures, joint replacement and c-sections. Tuesday the foundation added a detailed look at geographic variation in treatments for three more conditions: breast cancer, prostate cancer, and back and neck pain.

PIcking out eyebrow-raising numbers was no problem:

Men in Indio (Riverside County) receive brachytherapy, known commonly as radiation seeds, to treat prostate cancer at almost five times the statewide average.
Women in Healdsburg (Sonoma County) receive lumpectomy without radiation for early stage breast cancer at 270 percent of the statewide average.
People in Brawley (Imperial County) are nearly three times as likely to receive cervical fusion, where two vertebrae in the neck are fused together, for neck problems compared to statewide.

Low rates are easy to find, too. To name just one: women in Lancaster, northeast of Los Angeles, with early stage breast cancer receive lumpectomy with radiation at just 26 percent of the statewide average.

The question is why. Maribeth Shannon with the foundation says the variation is “just puzzling to us.” She stressed that the statewide average is not necessarily the “right” rate, but the state average is an estimate that’s easy to use as a benchmark.

In its analysis, the foundation accounted and adjusted for a host of patient characteristics that might skew the numbers. Still, the broad variation is there. Shannon pointed out that it would be “unusual” that patients would differ so significantly in what treatments they wanted, simply according to where they lived.

“It’s much more likely,” Shannon said, “that physicians practicing in that area tend to rely on that course of treatment over others. … It does seem to be more the physician preference than the patient preference.”

Professor Renee Hsia at UC San Francisco was not involved in the study. She agreed that physician preference matters, counter to what patients might think.

“A lot of patients out there think you go to one doctor and they will prescribe the same treatment,” no matter where you live, Hsia said, “because you go to medical school and there’s one answer.” Tuesday’s release shows there’s “a lot of variability.”

“The way your peers practice … in your group or in your hospital affects the way you practice also,” Hsia said. “I wouldn’t say it’s peer pressure, but it’s adapting to your current environment.”

Patients should be “good consumers”

Jeff Belkora, a UCSF professor of health policy says that physician preference for certain treatments needs to be “trumped” by what individual patients need. He called for patients to be good consumers and challenge their physicians. “We want to work with our physicians,” Belkora said. “We want to trust them. At the same time … any given doctor is different than any given patient, so we need to make them understand what we want and what we need.”

If you’re thinking that’s a tall order in the face of a challenging diagnosis, patients should remember that they likely have more time to weigh options than they might think. Belkora says patients need to make their diagnosis and treatment decisions into a “project.”

Elizabeth Becker of Piedmont did exactly that. She was diagnosed with DCIS, a very early stage non-invasive breast cancer, a year ago. She spent weeks researching her treatment options. The more she found out about the specific biology of her specific type of cancer, the closer she came to a decision. While DCIS is unlikely to recur as invasive cancer, in Becker’s case, if the cancer recurred, it was likely to be aggressive. Becker ultimately chose a mastectomy.

“I felt powerful,” she said, referring to the process of deciding as well as the options and choices she had. She also credited her doctor who held open-ended conversations with her. Becker said another doctor she had seen seemed to want to “teach me about breast cancer and then tell me my (treatment) option.” She was unimpressed.

Belkora says there are resources available for people facing treatment decisions. The first stop is research at reputable sites such as the American Cancer Society or the National Cancer Institute for those with a cancer diagnosis, he says.

The Informed Medical Decisions Foundation has decision aids for a wide variety of conditions, from cancers to back pain to heart disease. Health libraries at medical centers can also be a good resource.

But it’s easy to imagine that handling this “project” and doing all this research is a tall order for anyone staring down a diagnosis, let alone the most vulnerable among us, people who are low income, with little education, people who have limited English skills.

While Shannon said the foundation’s goal is in part to encourage patients to be more proactive, she also said the greater transparency could be an effective way to let “physicians know that they seem to be outliers,” she said. “that they seem to be prescribing a particular course of treatment much more often or less often than their peers across the state do.”

C-Section Rates Vary – Dramatically – Across the U.S.

Lisa Aliferis — Tue, 05 Mar 2013 23:26:06 +0000

Researchers list four recommendations to address the variation

By Alvin Tran, Kaiser Health News

(Photo: Kaiser Health News)

C-sections are the most commonly performed operation in the U.S., and a new study shows that a woman’s likelihood of having one varies ten-fold (from 7 to 70 percent) across the country.

And for women with lower-risk pregnancies? The range for them is 15-fold (from 2.4 to 36.5 percent), according to the researchers.

“We were really surprised by how much variation we saw,” said Dr. Katy Kozhimannil, an assistant professor at the University of Minnesota’s School of Public Health and the study’s lead author. Kozhimannil said she and her colleagues expected the rates of cesarean births among lower-risk mothers to vary less compared to the overall rates.

The study was published Monday in the journal Health Affairs.

The research team analyzed 2009 data from more than 1,000 hospitals in 44 states, taking patient characteristics into account as well as hospitals’ size, teaching status and geographic location.

The study’s findings suggest that small and rural hospitals showed more variability in C-section rates compared to other hospitals. Teaching hospitals, however, showed less variation in overall C-section rates.

Despite concerns about overuse of cesarean deliveries, Kozhimannil cautioned that some of these surgeries will always be necessary and researchers should be careful not to make doctors too uncomfortable about performing a cesarean. “When you see variation in something, it could suggest overuse or either underuse. I think it’s important to look out for underuse as well,” Kozhimannil added. “Cesarean deliveries save lives and every woman who needs a cesarean delivery should have one.”

Though her study was unable to explain why the variation in cesarean deliveries exists, Kozhimannil is optimistic that future research — studies that analyze the financial and payment incentives in place for managing pregnancy care — may help answer the question.

“I think it is important to look beyond the woman and her characteristics and beyond the clinicians and their characteristics and really look at the system-level factors that are driving these variability and patterns in care,” she said.

The study makes four key recommendations:

Better coordination among providers of maternity care to help reduce the need for C-sections
Better data collection about C-sections
Medicaid, which funds nearly half of all US births, should use its clout to help improve hospital obstetric practices
New policies to empower patients to make decisions about their deliveries — and to make data on the procedure more widely available.

“I think the fact that pregnant women cannot look up unbiased, easily available information on cesarean delivery rates in the hospitals from which they’re choosing is a problem that should be rectified,” Kozhimannil said.

Economist Rekindles Debate over Geographic Differences in Health Spending

state of health — Thu, 31 Jan 2013 22:28:27 +0000

By Jordan Rau, Kaiser Health News

An economist at the Federal Reserve has restoked the debate over the causes of regional differences in Medicare spending, and her analysis disputes some of the thinking behind a number of policy changes in the 2010 health overhaul.

The Obama administration and many prominent economists believe that as much as a third of the $2.7 trillion spent on health care may be due to wasteful practices of physicians and hospitals that could be eliminated without hurting patients. This is based on decades of research, principally by the Dartmouth Institute for Health Policy & Clinical Practice in New Hampshire, showing that Medicare spending in some regions of the country is significantly higher than others.

This geographic variation in spending, which the government has also examined, was a motivating force behind a number of government initiatives including changes in Medicare payment to reward hospitals and doctors who provide good care efficiently.

The Institute of Medicine has been studying the causes of regional variation, and its conclusions could influence more policies as the government seeks to clamp down on health spending. The policy implications are significant, because if these variations do help identify ways to economize, the government and private insurers might be able to cut large amounts from Medicare in some areas of the country without harming patients.

But the thesis has sparked passionate opposition by medical professionals and facilities and their lobbies in Washington.

The new paper by Louise Sheiner, an economist at the Federal Reserve, provides them with additional fodder. Sheiner examines health spending differences among states and the health of people in those states. She concludes health and socioeconomic factors — things like the prevalence of smoking, obesity and diabetes — best explain why health spending in some regions of the country is higher. That view has been argued for years by researchers such as Dr. Richard “Buz” Cooper of the University of Pennsylvania.

Sheiner writes:

[T]he variation in Medicare spending across states is attributable to factors that affect health and health behaviors, rather than practice styles. … It is not surprising that states in the South spend more on Medicare and have worse outcomes. These states perform significantly worse in numerous areas, including high school graduation rates, test scores, insurance, unemployment, violent crime, and teenage pregnancy. There are many ways that such differences can affect health utilization and outcomes, including differences in underlying health, social supports and social stressors, patient self-care and advocacy, ease of access to services, capabilities and quality of hospital and physician nurses and technicians, and cultural differences in attitudes toward care. A comparison of health spending in Mississippi with health spending in Minnesota is not likely to provide a usual metric of the ‘inefficiencies’ of the health system, nor is likely to provide a useful guide to improve the quality of care in places where it is lacking.

Sheiner’s analysis was issued as a working paper, which the Fed calls “preliminary materials circulated to stimulate discussion and critical comment,” not representations of the views of the central bank.

Nonetheless, the paper has circulated widely enough in health policy circles that the Dartmouth Institute this week rebutted it in a statement from Jonathan Skinner and Dr.Elliott Fisher, two senior Dartmouth researchers. They wrote:

The focus on states … ignores much of the variation within states, or … the greater than 1.5 fold differences in overall utilization rates across providers in the care of patients with health conditions (such as hip fracture or heart attack) that could not be accounted for by individual patient characteristics, nor, of course, by state level differences in population health. Most of the variations in spending are due to greater use of discretionary services, such as avoidable hospital readmissions or differences in the use of post-acute care, largely ignored in Sheiner’s analysis. … To argue that the geographic variations found in hundreds of studies are pure statistical artifacts seems farfetched.

The dustup is quickly spreading around health policy circles. On the Academy Health blog Thursday, economist Austin Frakt of the Incidental Economist rebutted Sheiner. He agrees with Dartmouth that Sheiner erred in focusing on differences between states rather than the individual level as Dartmouth does. Frakt writes:

I wish Sheiner’s conclusions could be believed. It would really simplify things if the vast majority of health spending variation was due to obesity, sedentary lifestyles, lack of insurance, and a few other things. Were that true, we’d know better how to shape policy. However, based on the body of evidence, it’s far more likely the story is more complex and also includes the efficiency with which care is delivered.

Editor’s note: The 1973 paper Small Area Variations in Health Care Delivery essentially launched the field of study of geographic variation in health care. That study looked at regional variation within the state of Vermont. In the study, researchers found the rate of tonsillectomy, to take one example, ranged from 13 percent in one area of Vermont to 66 percent in another.