Fw: Operations often depend on where you live ~ USA Today

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Sent: Thursday, October 05, 2000 1:37 PM

Subject: Operations often depend on where you live ~ USA Today

> http://www.usatoday.com/life/health/surgery/lhsur019.htm

>

>

> 09/19/00- Updated 10:36 AM ET

>

> Operations often depend on where you live

>

> Medical research questions just how informed patients are about surgeries

> before going under the knife

>

> By Dan Vergano, USA TODAY

>

> Discuss: Regional surgery ratesWhen Dianne Armitage discovered a lump in

> her breast, a diagnosis of cancer was followed quickly by a local

surgeon's

> recommendation: a mastectomy. Complete removal.

>

> What Armitage didn't know then, four years ago, was that a lumpectomy - a

> less-destructive alternative - was performed in the region around her home

> in Ottumwa, Iowa, less frequently than it is across the country.

>

> And the surgeon, she says, " didn't tell me the survival rate was the same

> for both procedures. "

>

> Only by chance did Armitage hear of the lumpectomy option and find a

> university hospital, and another surgeon, for the operation. In the

> process, she learned what researchers have known for decades: Where you

> live can determine the surgery you get.

> Also in this package:

> Good times roll up high surgery rates in Louisiana

> Texas amputations likely linked to diabetes

> Total trust in doctors is not wise

> Questions to ask your doctor

>

> The phenomenon, documented most prominently in a Dartmouth Atlas of Health

> Care series, has spurred debates not on the merits of any one procedure,

> but on whether patients get full information about their options before

> surgery.

>

> These debates are likely to continue because, despite advances in health

> care, the geographic variations don't appear to be changing. With the

> release next month of The Dartmouth Atlas of Musculoskeletal Health Care,

> the latest in the eight-year series devoted to all areas of health care,

> researchers continue to find surgical rates that vary widely across the

> nation. The result, experts suggest, is unnecessary suffering, sometimes

> even death, for patients who go under the knife without asking the right

> questions.

>

> " Local medical opinions regularly differ to the point that four times more

> people in one region get a surgery " than do their neighbors, says

> Wennberg of the Center for Evaluative Clinical Sciences in Hanover, N.H.,

> and head of the Atlas series.

>

> USA TODAY's analysis of the most recent Atlas data shows:

>

> In Bend, Ore., the rate for back surgeries is 7.3 for every 1,000 Medicare

> recipients -- more than four times higher than in Syracuse, N.Y., which

has

> 1.5 for every 1,000.

>

> Heart patients in Elyria, Ohio, get artery-clearing angioplasty at a rate

> more than seven times higher than in York, Pa., 360 miles away.

>

> Men in Baton Rouge, La., undergo prostate gland-removal surgery at a rate

> more than eight times higher than those in Tuscaloosa, Ala.

>

> The contrasts illustrate a surgical environment for patients filled with

> what Atlas researchers call " uninformed consent. " It is a situation, they

> say, born of inadequate medical science, opinion parading as knowledge,

> over-reliance on inadequately verified diagnostic tools, and basic

> inequities in the health care system.

>

> " The variations reflect a more profound problem with the American medical

> system, " says heart surgeon Baldwin, head of the Dartmouth Medical

> School, which is home of the center.

>

> He argues that the nation's view of health care as a business instead of a

> human right - including 73 million surgeries annually - has produced a

> surgical system that can proceed without any requirement that its

practices

> be validated by objective evidence.

>

> Hospitals and surgical groups regularly monitor the outcomes of surgeries,

> counters of the American College of Surgeons. But Atlas

> researchers suggest that such self-policing fails to ensure objectivity,

as

> the variability of rates demonstrates. A few generations ago, they note,

> tonsillectomies were a widespread feature of childhood - until researchers

> showed that public health was no worse in regions where few of the

> procedures were performed.

>

> Quietly, tonsillectomies died away, but only slowly and in random fashion,

> after many people lost their tonsils, perhaps unnecessarily.

>

> Surgery rates in the latest Dartmouth Atlases come from 1996 Medicare

data,

> the most recent available. With more than 38 million participants

receiving

> about 40% of all medical care nationwide, including surgery, the Medicare

> system and its patient trends mirror health care patterns closely,

Wennberg

> says. And they don't change much from year to year for specific regions,

> consistently following well-established trends, says , editor

> of the Atlas.

>

> " The Atlas data represents information we felt really needs to get out so

> health care professionals can communicate and start asking important

> questions, " says Don Nielsen of the American Hospital Association, which

> sponsors the effort.

>

> What doctors don't tell

> Surgeries with widest variation

> The following surgeries show the greatest variation in rates across the

306

> hospital regions studied:

>

> 1. Partial mastectomy

> 2. Prostate removal

> 3. Angioplasty

> 4. Lower extremity revascularization

> 5. Carotid endarterectomy

> 6. Back surgery

> 7. Thigh fracture repair

> 8. Hip replacement

> 9. Leg amputation

> 10. Heart valve replacement

>

> Something surgeons might not tell their patients, Nielsen and others say,

> is exactly how much isn't known about their treatment.

>

> " Our state of knowledge about a surgery all too often is based on

> speculation, " says neurologist Henry Barnett of the P. Robarts

> Research Institute in London, Ontario.

>

> For evidence, he points to a June New England Journal of Medicine study.

In

> it, Barnett and colleagues looked at the causes of strokes among 1,820

> patients. All had plaques clogging the blood vessels feeding their brains

> but showed no warning signs of stroke.

>

> Over five years, 45% of the strokes among study participants resulted from

> plaques in places other than the neck arteries breaking loose and gumming

> up blood flow to the brain.

>

> The researchers called on doctors to forgo a stroke prevention procedure

> called a carotid endarterectomy, in which plaque is removed from neck

> arteries, until more is known.

>

> However, an editorial that accompanied the study disagreed, citing studies

> showing an overall benefit from the surgery when a 70% or higher

> obstruction of those blood vessels existed.

>

> Partly as a result of such disagreements, carotid endarterectomy rates

> nationwide vary widely. Rates, for example, are two times higher among

> residents of Oxford, Miss., than they are 150 miles away in ,

Tenn.,

> according to this year's Dartmouth Atlas of Cardiovascular Health Care.

> Compared with El Paso, Texas, the Oxford rate is five times higher.

>

> And the procedure itself isn't always a success. A June 1999 study of

> carotid endarterectomy patients in The Lancet found that, following the

> procedure, at least 3.7% suffered stroke, heart attack or death as a

> result. About 130,000 such procedures take place every year nationwide,

> according to trade publication Medical Industry Today.

>

> " For lots of things, we don't have the answers right now, " says ,

> when discussing the most widely varying surgeries. Unlike drugs, for

> example, surgeries can freely become standard parts of medicine without

> clinical trials, the studies that randomly assign patients to either

> receive a new treatment or the current standard of care.

>

> At least 1 million carotid endarterectomies were performed before the

> completion of the first clinical trial involving the procedure, Barnett

> says.

>

> " It's kind of unsettling for people who assume we do everything on a

> scientific basis to find out a lot of treatment decisions depend solely on

> opinion, " says Wennberg, Wennberg's son, head of the Center for

> Outcomes Research and Evaluation in Portland, Maine, and editor of The

> Dartmouth Atlas of Cardiovascular Health Care.

>

> Uncertainty in medical science leaves room for outright physician

> preferences to creep in, says Donio of the People's Medical

> Society, a consumer advocacy group in town, Pa. " Docs who call

> themselves scientists can become very complacent about their favorite

> procedures, " he says.

>

> Some hesitancy to try something besides the tried-and-true operations

might

> spring from the tendency of new procedures to disappoint. A recent example

> is the " Batista " surgery, a once-promising Brazilian operation popular

> three years ago that cut a wedge of heart tissue away from individuals

> suffering heart failure in a bid to up their blood pressure. A

> still-unpublished Cleveland Clinic write-up of the surgery sent to USA

> TODAY by the clinic's McCarthy, a heart surgeon, concludes that it

> " is an unreliable alternative to cardiac transplantation except in special

> circumstances. "

>

> However, physicians often exhibit a blind loyalty to favored procedures

> that goes beyond scientific evidence, says. " A strong surgical

> group can push a treatment in a particular area, such as treatment for

> prostate cancer, and influence a lot of people. "

>

> Few doctors choose to wait

>

> In June, a study led by Floyd Fowler of the University of Massachusetts in

> Boston looked at how urologists and radiation specialists treated

> early-stage prostate cancer. Published in the Journal of the American

> Medical Association, the study found 93% of urologists chose surgical

> removal, while 72% of radiation specialists chose radiation treatment. Few

> chose to simply observe the often slow-growing cancer for signs of danger,

> a practice preferred by some doctors that's known as watchful waiting.

>

> " The problem probably reflects the educational background of surgeons, "

> says. Medical training generally emphasizes decisiveness, and more

> aggressive young surgeons might seek out departments with aggressive

> reputations.

>

> One possible result: curious juxtapositions. For example, the Hattiesburg,

> Miss., region has a radical prostatectomy rate of 4.2 per 1,000 Medicare

> patients, more than twice the national average, according to the Atlas.

> Meanwhile, too few took place in the nearby Oxford region for Atlas

> researchers to calculate a meaningful rate.

>

> " When I sit down with patients, I can't show them a ream of papers, but I

> can give them my honest opinion " when discussing a radical prostatectomy,

> says urologist Resnick, an American Urological Association

> spokesman. " The variation exists, but I think most physicians give a fair

> perspective. "

>

> Though no one wants a timid surgeon, excess self-assurance might result in

> excess surgery. In August, the American College of Obstetricians and

> Gynecologists announced that 22% of births took place by Caesarian section

> in 1999, a rise over the previous year. A group spokesman attributed the

> increase in the procedure - one that carries at least three times the

> overall risk of dying than during natural birth - to physician preference.

>

> For a decade, federal health officials have called for a national

C-section

> rate of 15%, which would have resulted in 273,000 fewer such births last

> year.

>

> Adding to disputes, medicine's high-tech diagnostic tools might ratchet up

> surgery rates. " The up-front risks of most diagnostic tests are almost

> zero, " Wennberg says. " Except, they may lead to a cascade of further

> tests that lead you, perhaps, to an unanticipated trip to the operating

> table. "

>

> Atlas researchers have found an " almost-perfect " connection between

regions

> with high rates for angiograms - X-ray tests for heart and artery

blockages

> - and rates of bypass surgeries. More tests accompanied more surgeries

> without any great difference in heart disease rates between regions.

>

> " Every cardiology program with a mortality problem that I've investigated

> had an excessive diagnostic pattern, " Baldwin says.

>

> Finally, problems of access and poverty might explain some variations.

> Lumpectomy rates are low in much of the Midwest, for example, partly

> because there are fewer facilities to perform the follow-up radiation

often

> recommended.

>

> 'The doctor knows best'

>

> " We've found in counties with significant amounts of farmland that women

> are more likely to get a mastectomy, " which doesn't always require

> follow-up radiation, says Rescigno of Memorial Sloan-Kettering Cancer

> Center in New York, who led a National Cancer Institute tumor registry

> study in 1998.

>

> And some patients simply might not research alternatives, says Fran Visco

> of the National Breast Cancer Coalition.

>

> " I said, 'OK, the doctor knows best.' I went along with it, I put up with

> it, and I paid for it, " says Darrell Wallace, a former Philadelphia

backhoe

> operator and self-described " blue-collar guy " who injured his back on the

> job in 1992. In March, a jury awarded him more than $20 million in damages

> against his surgeon, who offered him a spine-fusing surgery instead of

> physical therapy, Wallace says. He now requires a hockey-puck-size

morphine

> pump, implanted in his right side, to kill the pain from two failed back

> surgeries.

>

> " The pain is still there. My condition is still there, " Wallace says. " The

> only thing (the implant) does is make it tolerable most of the time. " His

> case remains on appeal.

>

> Atlas researchers say that the problem for patients is not whether their

> region has the " right " rate of a surgery, but whether they ask questions

> and know of their options before making a decision.

>

> " Very often, if we don't ask a surgeon for the alternatives, they don't

> tell us, " says Donio of the People's Medical Society.

>

> Even when patients ask, most hospitals don't readily provide death rates

> for operations, says Rose, chief surgeon at Columbia Presbyterian

> Medical Center in New York. In August, his hospital inaugurated its

> Outcomes Report, a physician handbook that lays out the facility's

surgical

> mortality rates. " The ultimate decision-maker must be the patient, " Rose

> says.

>

> For time-pressed physicians, the Atlas researchers developed patient

videos

> that detail the pluses and minuses of surgeries, using statistics from

> clinical trials and admitting where more isn't known. endorses

this

> notion, part of a wider trend toward " evidence-based medicine, " and adds

> that the American College of Surgeons is " increasingly moving toward this

> approach, " particularly with cancer.

>

> Wennberg says his center plans to place regional Atlas data on its

Web

> site by the end of October. Eventually, he would like to add individual

> hospitals' surgical rates. Even then, Wennberg adds, all patients should

> carefully research their condition and ask their physicians whether

they've

> discussed the risks and benefits of all options, including doing nothing.

>

> " You want to trust someone who says he'll help you, " says Armitage, who

> lives in Santa Barbara, Calif., works for the Love M.D. Breast

Cancer

> Foundation and is healthy after her lumpectomy. " I never thought I'd have

> to find all this out on my own. "

>

>