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Regional Variation in Elective Surgery

A recent report by the Dartmouth Atlas team finds significant geographic  variation elective surgery.

…if you have heart disease and live in St. Cloud, Minnesota, you are half as likely to undergo cardiac bypass surgery than if you live in Detroit Lakes, and more than twice as likely to undergo back surgery than if you live in Rochester. If you have gallstones and live in Wadena, you are three times more likely to have your gall bladder removed than if you live in Minneapolis.

More interesting, however, is what causes the regional variation.  Significant regional variation only occurs when there is a lack of professional consensus on the correct treatment for any condition.

For example, there is considerable disagreement among surgeons about the need for back surgery, its effectiveness, and even the best way to diagnose the cause of back pain. This lack of agreement stems in part from a lack of studies, called clinical trials, which provide the scientific evidence that clinicians need in order to know how best to treat their patients. With no consensus about how to diagnose and treat back pain, the rate of back surgery varies a great deal from place to place.

On the other hand, when clinicians agree on how to treat a condition, there is often relatively little geographic variation in the care patients receive. Take the example of hip fracture. Diagnosing a broken hip is not difficult, and all physicians agree that patients with a broken hip must be hospitalized and undergo a procedure to repair it.

The goal, then, seems to be to establish consensus on treatment.  For many conditions, however, a consensus may develop but this consensus may decide that treatment should vary depending on the severity of the disease.  In this case, even if a consensus is established, physician preferences will still play a large role since they are the ones who determine the severity of each condition.


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