For weeks you've suffered from yet another bout of back pain so severe you can hardly get out of bed in the morning. Your family doctor and the orthopedic surgeon she referred you to both say you're a good candidate for spine surgery. And it seems like everyone is having it — your next-door neighbor, your boss, the waitress at your favorite restaurant. You set a date for the procedure.
But what if you knew that your town had one of the highest rates of back surgery in the United States, nearly three times the national average? And that an orthopedic surgeon 50 miles away would advise you to wait awhile and see if the pain went away on its own? Would that change your decision?
Mounting research suggests that where you live plays a significant role in the health care you receive.
"We've found that geography is often destiny," says James N. Weinstein, D.O., director of the Dartmouth Institute for Health Policy and Clinical Practice, where this field of study was pioneered. "It's not that the rates of disease are different, it's the way they're treated that's different — from prevention to diagnosis to long-term care."
Luckily, you don't have to accept the health care your neighborhood allots you. By asking pointed questions of your physician, for instance, or knowing when to seek a second opinion from a specialist in another state, you can turn these differences to your advantage. Here, the region-by-region facts, as well as local hot spots that have questionable (or progressive) practices, and — most important — how to use this information to get the very best health care, wherever you call home.
The states: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, Wyoming
Prevention is neglected
When it comes to women's preventive health care, the West scores low. In 2006, less than 70 percent of women over age 40 in "big sky" states like Idaho, Utah, and Wyoming had gotten a mammogram in the past 2 years, compared with the national average of 77 percent, according to the CDC. The proportion of women getting Pap tests is also relatively low — though both tests have been shown to save lives by detecting cancer in treatable stages. Another preventive tool, cholesterol screening, also lags in many of these states.
Patients are informed
Medical decisions aren't always clear-cut. One person with terminal cancer, for instance, might want to try all available options, no matter how grueling — while another might prefer to enjoy her remaining days free of treatment and its side effects. In other words, the "right" decision is often a matter of how a patient weighs the pros and cons. With a pilot project started in 2007, Washington became the first state to push doctors to share all relevant information with anyone facing an important elective surgery. Experts say that those discussions are critical in allowing the patient's values to guide the decision.
More prostate surgery
Prostate cancer often presents a man with difficult decisions, because in many cases, it's not clear whether it's better to have surgery or radiation — or just to opt for "watchful waiting." The uncertainty leaves room for doctors to settle on very different approaches. In a scattering of areas in the West, particularly Los Angeles and San Jose in California and the whole of Utah, men are nearly twice as likely to have surgery as those in Connecticut, according to a 2005 study by UCLA researchers.
The reason isn't known, says researcher Dr. Tracey L. Krupski, an assistant professor of surgery at Duke University Medical Center. What is certain: Surgery can cause incontinence and erectile dysfunction — yet may lengthen life in some cases — so it's a decision that should be made jointly by the patient and physician, not by the luck of the zip code.
Better end-of-life care
The states of Utah and Oregon are seen by many experts as models for restrained but responsible care for terminally ill patients. In a 2006 Dartmouth study that analyzed the records of 4.7 million Medicare patients, the researchers found that people in Utah had an average of just 17 doctor visits in the last 6 months of life, compared with 41.5 visits in New Jersey.
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Hospital stays were shorter, too: Patients in Utah, Oregon, and Idaho spent an average of 7 to 8 days in the hospital in their final 6 months, roughly half as many as patients in Hawaii, New York, New Jersey, and D.C.
Yet less care equaled better care. The Dartmouth researchers found that elderly patients in the West actually lived slightly longer — perhaps because every day in the hospital and each procedure brings risks of infection and other complications.
Casper, Wyo.: Too many back surgeries
Numerous studies have shown that back pain often goes away if you give it enough time, so in much of the country doctors recommend that patients wait it out. But in Casper, surgeons operate. According to 2005 Medicare data, Casper had the highest rate of back surgery in the country — 11 per 1,000 Medicare enrollees, more than 2 1/2 times the national average and nearly 5 times the rate in Vermont and New Jersey.
Researchers aren't sure why people in this city of 50,000 rush to go under the knife, but it may be a classic case of what's known as a "surgical signature": When the best treatment is unclear, local doctors build a consensus. Other hot spots for spine surgery include Boise, Idaho; Great Falls, Mont.; and Mason City, Iowa.
The states: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia
Higher hysterectomy rates
Southern women are more apt than women elsewhere to have their uterus removed for problems such as fibroids — 6.2 per 1,000 women in 2004, compared with 3.7 per 1,000 in the Northeast, according to the most recent data from the CDC. (Rates for the West and Midwest fell in between.) What's more, Southern women lose the organ at age 44, on average, compared with age 49 for women who have the surgery in the Northeast.
"When a woman hears she needs a hysterectomy, she must get more information, wherever she lives," says Dr. Michael Broder, an assistant clinical professor of obstetrics and gynecology at UCLA. "It's such a commonly overdone operation."
In a 2000 study, Broder and colleagues found that 70 percent of hysterectomies at nine medical practices in Southern California were recommended inappropriately: Either the patients weren't adequately evaluated or they weren't offered less invasive options, which include drug therapy and surgery to remove fibroids while sparing the uterus.
Crowded emergency rooms
Because a relatively high number of Southerners lack health insurance, preventive care is hard for many to afford — and that can allow treatable conditions to become emergencies, says Dr. Frederick Blum, an emergency physician in Morgantown, W.V., and a past president of the American College of Emergency Physicians. The resulting ER overload affects everyone in the state, with victims of car crashes jockeying for medical attention with patients in diabetic shock. In West Virginia, for example, there were 629 emergency room visits per 1,000 residents in 2006, compared with an average of 396 per 1,000 residents across the nation.
Women still take hormones
Use of estrogen supplements — either short-term to treat hot flashes or long-term to protect the bones — has declined dramatically since government studies showed they can increase the risk of developing breast cancer and heart disease. But the drop-off has been uneven, according to a study released this year by researchers at Express Scripts, a pharmacy benefits manager providing services to more than 50 million members. In Louisiana, the number of women filling estrogen prescriptions shrank about 40 percent from 2000 to 2006 — but tumbled a full 74 percent over the same time span in New York. The findings underscore the fact that doctors don't necessarily react to news (or to drug risks) in the same way — so a patient needs to ask questions and be her own advocate.
Atlanta: Better access to breast reconstruction
Surprisingly, less than 20 percent of women nationwide who have a mastectomy get reconstruction at the same time, showed a 2006 study at the University of Michigan — though other research finds that it can bring big emotional benefits. But 35 percent of women in the Atlanta area had their breast rebuilt. Breast surgeon Dr. Amy Alderman, who led the study, points out that one of the most common reconstruction procedures, the "TRAM flap" (which uses skin, fat, and muscle from the abdomen to refashion the breast), was developed by an Atlanta surgeon. The homegrown nature of the technique may make local surgeons more willing to suggest it, Alderman says.
The states: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin
Knee surgery rates double
People here are prone to knee replacements, according to 2005 Medicare data. The rate in Nebraska was 50 percent higher than the national average — more than double the rate in much of the Northeast. The phenomenon may be partly explained by the greater number of overweight people, who tend to have more knee problems. But Dr. Ronald P. Grelsamer, an orthopedic surgeon and author of several books on knee surgery, suggests that because of the distances Midwestern patients must sometimes travel, physicians may be quicker to offer end-stage treatment when a less invasive one — such as occasional injections — might do the trick. "With knee replacement, it's a matter of how long a person wants to tough it out before accepting the risks of surgery," he says. That's a decision for the patient, he adds — not the doctor.
Less help for obesity
Midwestern states, along with the South, have the highest rates of morbid obesity in the country — more than 4 percent of women in their 50s weigh so much that they're at greatly increased risk of heart disease and other deadly ills. For them, weight loss surgery can be lifesaving, says Dr. Benjamin Poulose. But in a 2005 study at Vanderbilt University, he and his colleagues found those regions had the lowest rates of the surgery: A Midwestern or Southern candidate for the surgery was just 25 percent to 50 percent as likely to get it as if she lived in the Northeast.
Elyria, Ohio: Sky-high angioplasty rates
For years, the city of Elyria has had the nation's highest rate of angioplasty, a heart treatment that involves threading a balloon catheter through a blocked artery. Local statistics have stood out since at least 1996, according to Dartmouth researchers; by 2003, the city had 42 procedures per 1,000 Medicare enrollees, compared with just 11.3 per 1,000 in the rest of the nation. A cardiologist's decision to perform angioplasty instead of treating with drugs (or suggesting bypass surgery) is a judgment call in most cases, and the Dartmouth experts say whenever there's that kind of uncertainty, a physician practice or hospital can become wedded to a single approach to the problem.
The states: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont
Women get better care
Northeastern women get more frequent Pap tests and mammograms than women who live elsewhere in the country. States in the Northeast tend to have patient-friendly policies — ones that boost the number of women with health insurance, for example, or make it easier for workers to take time off to help a family member with medical problems. The result: The region (especially New England) is a good place for women to live, according to a report by the National Women's Law Center and Oregon Health & Science University, which rated states on nearly 100 factors. "They've put resources into improving the health of their populace, and that pays off," says Dr. Michelle Berlin, an author of the report.
Patients spend an extra 16 percent
Northeasterners tend to see more doctors (including pricey specialists) and get more tests than people in other parts of the country, and they feel it in the pocketbook. Annual costs per person totaled $6,171 in the Northeast in 2004, compared with a national average of $5,283, according to a report by the Centers for Medicare & Medicaid Services. But that extra care isn't necessarily a good thing, says Dr. Elliott Fisher, a researcher at the Dartmouth Institute. In a 2006 study, patients who saw appreciably more doctors were actually slightly more likely to die, probably because of complications that can accompany procedures, and similar factors. Surprisingly, says Fisher, "the evidence suggests that higher spending is actually associated with lower quality."
Breast cancer surgery may be less invasive
Although numerous studies have shown virtually equal survival rates for women who get breast-conserving lumpectomy versus those who have a mastectomy, treatment varies significantly from state to state. In a 2006 study at the University of Louisville, 71 percent of breast cancer patients in the Northeast had a lumpectomy, compared with just 63 percent of women in the Southeast. How a doctor presents the options can tilt a woman's decision, says Dr. E. Dale Collins, medical director of the comprehensive breast program at Dartmouth-Hitchcock Medical Center. So can other factors, like how easy or difficult it is to get follow-up care. Most lumpectomy patients need multiple radiation treatments, she points out, and in some other areas of the country, you might have to drive 2 hours a day to get it. "That might change your treatment choice," she says.
Newark, NJ: Over-hospitalization
Most people hope to spend their final days at home or in a hospice, but in this city, nearly 50 percent of elderly patients die in a hospital, the most expensive and impersonal way to go. It's the highest rate in the country, according to a review of Medicare data from the mid-1990s. (In Bend, OR, where rates are among the lowest in the United States, fewer than 20 percent of Medicare deaths were in a hospital.) One possible reason: Newark has a lot of hospital beds for a town of its size — and studies show that can affect doctors' behavior. "The more hospital beds there are, the more likely a person will be hospitalized rather than treated at home," says Fisher. "It's easier for the physician, but it's not always best for the patient."
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