New Dartmouth Atlas report with new national data but 1st state-specific look – Minnesota

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A new report (pdf file) from the Dartmouth Atlas Project and the Foundation for Informed Medical Decision Making shows that men over 65 with early-stage prostate cancer in San Luis Obispo, Calif., are 12 times more likely to have surgery to remove their prostate as those in Albany, Ga. 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.

We’ve seen these national Atlas reports before.

mn atlas cover.jpg

But for the first time, the Atlas offers a look at an individual state, and they began with Minnesota – largely because of the inroads that have already been made there with shared decision-making – one of the emphases of this report. It’s a report on elective, or preference-sensitive procedures:

• mastectomy for breast cancer;

• coronary artery bypass surgery;
• percutaneous coronary intervention (stents and angioplasty);
• back surgery;
• knee and hip joint replacement;
• carotid artery surgery;
• gall bladder removal;
• radical prostatectomy for prostate cancer;
• and prostate cancer screening.

A Reuters story emphasized the shared decision-making aspect to the findings:

Dr. Michael Barry, president of the Foundation for Informed Medical Decision Making who helped lead the study, said the findings suggest patients are often not full partners in making decisions about how they want to be treated.

“We found patients were really ill-informed. They weren’t asked their opinions as often as they should have been. Doctors were often assuming they knew patient preferences rather than asking,” said Barry.

The Star Tribune reported:

Medicare beneficiaries in Crookston and Warren, Minn., or example, are more likely to receive stents or angioplasty procedures than are patients in other parts of Minnesota, even though the closest cardiology office is in Grand Forks, N.D. The border city has procedure rates that double state and national averages, as well.

That was news to Dr. Abdel Ahmed, chief of cardiology with Grand Forks’ Altru Health System. While his group prefers these procedures over bypass surgeries for patients with chest pain, he said conservative options are always discussed.

He wondered if aggressive screening by referring physicians resulted in more procedures. Or perhaps patients weren’t being referred early enough when conservative care would help.

Either way, he said, the figures merit a review. “Double deserves a look,” he said.

MN atlas.jpgThe Pioneer Press headlined it:

Minnesota’s rate of five surgeries is higher than U.S. average

Findings call for more shared decision making by patients and doctors

And they included the graphic at left. The story concluded:

“On prostate cancer surgery, the Dartmouth researchers said that local men who undergo prostate cancer surgery might not be hearing enough about alternatives such as radiation or active surveillance of their cancers. Prostate cancer surgery might reduce deaths, but it also brings a significant risk of impotence and incontinence.

But Dr. Peter Sershon, a surgeon at Metro Urology in Woodbury, offered a different interpretation, saying men in St. Paul could be benefiting from the increased use of prostate cancer surgery. Smaller communities might be able to offer prostate cancer patients access to radiation therapy, he said, but not specialized surgeons who can offer operations with fewer side effects.

“We’ve got the surgeons in town who can do a really good job with the operation,” Sershon said.”

It’s always interesting to see how many in medicine refute evidence or spin it their own way. For a long time, people who don’t like what the Atlas data show counter that high-use areas might be better off – even though the evidence through all the years does not support that conclusion. Doctors often say, “Our case mix is tougher…our experience is better”, etc.

Instead, the Atlas data consistently help us understand that in health care, more is not always better.

And the shared decision-making experience shows that when you fully inform and involve patients in the decision-making process, they are often more risk averse than their doctors – and more satisfied with their outcomes.

DISCLOSURE: My project is funded by the Foundation for Informed Medical Decision Making. However, I have complete editorial independence. No one at the Foundation has ever told me what to write about or how to write it. They support this project because they believe, as I do, that news coverage may have a powerful impact on individual decision-making.

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