Report points to variances in health care procedures, based on where patients live

Dartmouth study examined rates of mastectomies, back surgery and other procedures

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Iowans diagnosed with early-stage breast cancer are five times more likely to undergo a mastectomy in Sioux City than in Dubuque.

That discrepancy is one of numerous examples pointing to variations in health care based on a patient’s location, according to new research from the Dartmouth Atlas Project, based at Dartmouth College.

The report, which compares rates of elective procedures among Medicare recipients, showed that surgeries depend not on how sick patients are, but where the patient lives, said Shannon Brownlee, a Dartmouth instructor and lead author of the report.

“(Patient) preferences are often not taken into account,” Brownlee said Wednesday, during a conference call with reporters. “It’s often the physician’s opinion that ends up winning the day.”

With mastectomies, the rates from 2008 to 2010 varied from .3 per 1,000 female Medicare patients in Dubuque, to .6 in Cedar Rapids; .8 in Iowa City and Des Moines, and a high of 1.7 in Sioux City.

The national average is .9 per 1,000 patients.

Brownlee said past studies have shown patients generally prefer less aggressive, or less invasive, procedures. That could mean, for example, treating a heart condition with medication as opposed to a surgical stent.

Some patients might prefer a mastectomy, in which the entire breast is removed, compared to a lumpectomy with radiation, which preserves the breast tissue, she said.

“There’s more than one way to treat the patient’s condition,” Brownlee said, but when patients delegate that decision to their doctor, the result can be different than if the patient had been fully informed about treatment options.

Besides mastectomies, the study examined rates of back surgery, knee and hip replacement and seven other procedures.

The rates of back surgeries were lowest in the Cedar Rapids region, at 3.6 per 1,000 Medicare patients, compared to 3.8 in Des Moines; 4.3 in Dubuque; and 4.7 in Iowa City, with the highest at 6.7 percent in Mason City.

Nationwide, the average was 4.7 in 2010.

Co-author Dr. David Goodman, co-principal investigator for the Dartmouth Atlas Project, said research has shown the effectiveness of surgery for lower back pain “is quite marginal.”

Rates of back surgery and other procedures often reflect local practice styles, which vary from place-to-place, Goodman said.

Dr. Bobby Koneru, medical director for the Wendt Regional Cancer Center at Finley Hospital in Dubuque, said Dubuque surgeons are generally open to radiation and breast-conserving lumpectomies.

Koneru said lumpectomies are an option when breast cancer is diagnosed early, so better screening rates may explain some of the statewide discrepancies. Others include whether or not radiation is readily available in a community – patients may opt for mastectomy over driving several hours for five to six weeks for radiation – and whether or not surgeons advocate for breast conserving measures, he said.



“Improving Patient Decision-Making in Health Care,” from the Dartmouth Atlas Project, examined rates of common surgical procedures and PSA testing among Medicare beneficiaries in Iowa, Kansas, Minnesota, Missouri, Nebraska, and North and South Dakota. See the full report at:

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