The Dartmouth Atlas has focused on geographic variation in costs and use of services across the nation among Medicare beneficiaries. The latest report examines the role of patient involvement or lack of involvement in decision-making as a factor in that variation. Elective surgery rates are examined, since that is an area where patient choice should be at work, but apparently often isn’t. (DA Report) The report begins by discussing the importance of providers working to ensure that patients are fully informed and that the providers respect patient choice, not necessarily what the provider thinks should be done. The research showing that this often does not happen, and that it is responsible for much of the geographic variation that exists is reviewed.
The report then looks at eight examples of health needs that are highly preference sensitive, in other words, there are viable options for treatment, including early-stage breast cancer, low back pain, gallstones, enlarged prostate and carotid artery disease. Each of these shows very significant variation in treatment in different locales. There was often a 2, 3 even 6 times variation in the rate of surgery for some of these conditions. Variation in Minnesota is highlighted as an example, showing that even in very close areas, big differences in treatment exist. The discussion of these eight conditions contains a lot of useful information for patients. The last section of the report gives patients advice on how to ensure that they are knowledgeable and that their decisions are respected.
This report is an extremely valuable contribution to the discussion about getting patients engaged in their health care and supports the notion that physicians often either don’t try to understand or aren’t skilled at understanding patient preferences for care. Much research has shown that informed patients are usually more conservative in treatment choices than are their physicians, so this can be a critical area for focus not only to contain costs, but also to improve quality and patient satisfaction. One potential flaw in the theory is that many of the most expensive patients are older and often not capable of making decisions about their care, due to dementia or physical deficits. Surrogates then need to be brought into the process and those surrogates need to have a clear understanding of the patient’s preferences.