An elderly resident of Miami Beach is one-third as likely to have a knee replaced as one living in Roanoke Rapids, N.C., and Hialeah men on Medicare are far more likely to have procedures done to their prostates than the national average.
These are two of the latest findings from the Dartmouth Atlas Project, which for more than 20 years has been studying disparities in American healthcare.
Shannon Brownlee, lead author of the latest report, said the findings have “huge” implications for the nation’s lawmakers, who know they must find ways to slash healthcare costs in Medicare and Medicaid if the country wants to reduce the ever-mounting federal deficit.
The study is not intended to show what is a correct rate for any procedure, Brownlee said. “A lot of cases there is no one right answer,” he said, but Dartmouth hopes that the study will alert patients that they should participate in decisions with their doctors.
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“Decisions around elective procedures should be made with patients, not for them,” Brownlee said. “But all too often what the patient might prefer doesn’t even come up, and it’s the clinician’s opinion and personal beliefs that determine the course of treatment.”
Still, in the larger picture, Dartmouth’s studies have shown that doctors’ practice patterns vary widely and often may be more important than medical necessity in determining care. One well-known study a quarter-century ago showed that women in one New England town were three times more likely to have hysterectomies than women in a nearby town.
The latest study, using data from 2008 through 2010, shows men on Medicare in Hialeah are 55 percent more likely than the national average to have transurethral prostate resection, a procedure to shrink enlarged prostates. Hialeah men aged 66 to 74 are more than twice as likely to have PSA exams to test for prostate cancer.
“Hialeah is very busy messing with men’s prostates,” Brownlee said. “That transurethral rate is way high. And so is gall bladders.” The study found that Hialeah seniors are 58 percent more likely to have their gall bladders removed than the national average.
“I’m not sure what’s going on,” Brownlee said.
Tenet Healthcare runs the two largest hospitals in the city, Hialeah and Palmetto General. A Tenet spokeswoman referred questions to Linda Quick, president of the South Florida Hospital and Healthcare Association.
“Frankly, I don’t know which comes first,” Quick said. “Physician influences and preferences, practice patterns or community choice.” Doctors may be influencing patients — or patients’ preferences for aggressive care may be attracting providers who will provide the care they want.
With prostates, there may also be an issue of how up-to-date a provider’s medical education is. While aggressive prostate testing and procedures used to be recommended for men, Brownlee said that definitive studies now recommend a more cautious approach.
“The folks at Dartmouth have been saying there are real concerns about the cost benefit of PSA tests,” Brownlee said. The issue is that PSA tests can produce false positives that lead to unnecessary biopsies, and even if older men are shown to have prostate cancer, procedures to deal with it can be problematic, Brownlee said.
Two “very large studies” — one in the United States and one in Europe — showed that “there might be some small mortality benefit but at a very high price for men,” with “very high” rates of impotence and incontinence, Brownlee said.
Many urologists disagree and continue to maintain that aggressive treatment is beneficial, but the main point of the Dartmouth work is that patients should understand their choices.
Brownlee said doctors and hospitals often say they simply do what patients want, but the data doesn’t show consistent trends across all procedures. Hialeah seniors, for example, are three times less likely to have back surgery or knee replacements than the national average.
“A lot of this is called the hidden curriculum,” in which doctors tend to make decisions based on what they were taught during their residency programs, Brownlee said.
In fact, even within South Florida, patterns vary widely. Seniors in Miami Beach get knees replaced and have coronary bypass surgery at about half the national average. In South Miami, they’re much less likely to have angioplasty, while a senior in Miami is 15 times more likely to be given a PSA test than a man in Lebanon, N.H.
The challenge is to find standards of evidence-based medicine, so that unnecessary procedures can be eliminated, said Brownlee, author of the book, Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.”
“A conservative estimate is that about 30 percent of the money we spend on healthcare is wasted,” Brownlee said. “I think that’s a low estimate.”