Where you live determines your quality of care

By Rachele Kanigel

updated 8:31 a.m. ET July 1, 2008

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 West
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.

Why “where” matters Three reasons researchers say location determines your care: If you build it, they will come You'd think that the number of people who need hospital care in an area would determine the number of hospital beds — but it seems to be the other way around. Boston has about 60 percent more hospital beds per person than New Haven, CT, and researchers have found that Bostonians are about 60 percent more likely to be hospitalized, though they're no sicker. "As we build capacity in the health care system — more hospital beds, more MRI machines — we use it," says James N. Weinstein, DO, MPH, chair of orthopedics at Dartmouth-Hitchcock Medical Center. Disturbingly, studies show the quality of health care is somewhat worse in higher-spending regions, maybe because, infection-wise, a hospital is not a healthy place to be. Doctors agree to agree For certain conditions, there's very little variation in treatment: If you have a hip fracture, you need surgery, wherever you live. But for many ailments, the evidence for a particular treatment is not so clear, which leaves room for lots of variation. Often, though, doctors who work together eventually build a consensus. "Surgical signatures," as the phenomenon is called, may develop as young doctors mimic the practices of their mentors or as they discuss cases over cafeteria lunches. So while physicians in one region may tend toward watchful waiting in the treatment of prostate cancer, for example, those in another area may feel that more aggressive treatment is warranted. Plain old profit The sorry fact is that sometimes doctors recommend a treatment because it's more profitable. Physicians who have a financial interest in an imaging center, for example, may be tempted to suggest an MRI even when it's not absolutely necessary. Sometimes, they recommend much more than an exam: A few years ago, Tenet Healthcare Corporation agreed to pay more than $50 million (without admitting fault) to settle government charges that doctors at the Redding Medical Center in Redding, CA, performed unnecessary heart procedures and surgeries on hundreds of patients.

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.

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.

Hot Spot
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 South
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.

Hot Spot
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.

MORE FROM HEALTH CARE

Health care Section Front

Urban medical schools feel weight of uninsured Live to 43 or 86? Depends on where you live Blood test OK’d for heart transplant rejection Study won’t sway company on eye drug cost Exoskeleton suit helps paralyzed people walk Uninsured pay $30 billion for health care Major life changes may spark chronic headache Face transplants could one day be routine Medicare gap leads to elderly skipping drugs Judge: Drug maker must give trial med to teen Health care Section Front   Add Health care headlines to your news reader: