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Variation in Surgical Procedures

Variation in Surgical Procedures

There is a remarkably high degree of variation in rates of common surgical procedures across hospital service areas dominated by academic medical centers. Patients' chances of having prostate surgery, CABG, or vascular surgery depend as much on where they live as the medical problem that brought them to a physician. While these local practice patterns are invisible to residents, attending physicians, and patients, they reflect important differences in patient care that should be understood by medical students choosing a surgical training program.

Table 2 shows the procedure rates for the 19 HSAs associated with the 23 teaching hospitals. Each of these HSAs' rates demonstrates practice styles that influence resident training. These data reveal at least a twofold variation in rates among these HSAs for every one of the procedures listed. For some procedures, the variation was even greater. For example, the incidence of lower extremity bypass in Baltimore was five times that in Temple, Texas. The incidence of radical prostatectomy in Salt Lake City was more than three times that in San Francisco. In addition, the table demonstrates that a high frequency of one procedure in a particular region did not necessarily mean high rates for all procedures. For instance, while the rate of transurethral prostatectomy in Los Angeles was among the highest in the group of HSAs examined, the rates of hip replacement, CABG, and carotid endarterectomy were among the lowest. For the HSAs studied for this report, many procedure rates were below the national average, and, other than the rate for lower extremity bypass in Baltimore, none exceeded two times the national average rate for that procedure.

Table 2. Inpatient surgical procedure rates per 1,000 Medicare enrollees (2008-10)

CABG = Coronary artery bypass grafting      LEB = Lower extremity bypass
PCI = Percutaneous coronary intervention      TURP for BPH = Transurethral resection of the prostate
Hip rep. = Hip replacement      for benign prostatic hyperplasia
Knee rep. = Knee replacement RP = Radical prostatectomy
Back surg. = Back surgery CH = Cholecystectomy
CE = Carotid endarterectomy MC = Mastectomy for cancer
Hospital service area
(HSA)
CABG PCI Hip rep. Knee rep. Back surg. CE LEB TURP for BPH RP CH MC
Los Angeles, CA 1.6 6.5 2.3 5.9 4.6 0.8 0.8 3.6 1.6 3.2 0.7
San Francisco, CA 1.2 5.5 2.5 4.3 2.9 0.8 0.7 3.2 0.8 2.5 0.2
Stanford, CA 1.5 3.7 5.3 6.8 4.3 0.8 0.6 3.2   1.5  
Chicago, IL 3.1 8.0 3.3 6.3 2.9 1.4 1.1 3.6 1.3 3.4 0.9
Indianapolis, IN 3.5 9.7 4.3 9.4 4.0 2.2 1.1 1.9 1.5 2.6 0.5
Baltimore, MD 3.8 9.8 4.0 9.9 5.9 2.8 2.1 2.2 0.8 3.3 1.0
Boston, MA 2.0 5.5 3.1 5.9 2.8 1.4 0.7 4.1 1.0 2.5 0.6
Ann Arbor, MI 3.2 6.7 4.9 9.2 3.8 1.8 0.8 2.1 1.6 2.5 0.8
Rochester, MN 2.9 7.3 5.8 11.7 3.5 1.3 0.5 1.0 2.2 2.5 0.8
St. Louis, MO 3.5 8.4 3.8 10.1 4.1 1.9 1.0 2.1 1.8 3.9 0.6
Manhattan, NY 1.8 8.9 3.5 4.5 3.0 0.8 0.8 3.2 1.4 1.9 0.9
Durham, NC 2.6 4.5 3.8 8.8 5.1 1.0 0.5 3.5 2.0 2.4 0.6
Cleveland, OH 2.9 7.7 4.4 8.6 3.3 1.7 1.0 2.3 0.9 3.1 0.7
Philadelphia, PA 2.4 7.3 3.0 5.8 2.7 1.1 0.8 3.0 1.0 2.9 1.0
Pittsburgh, PA 3.4 7.6 3.9 8.1 5.2 1.4 1.0 2.7 0.8 3.5 0.8
Nashville, TN 3.8 6.9 3.5 8.1 6.3 1.6 1.2 2.0 2.4 3.1 0.4
Temple, TX 3.6 4.4 2.9 10.2 2.4 1.2 0.4 0.9 1.7 2.8  
Salt Lake City, UT 2.1 5.2 5.1 11.9 5.7 1.1 0.5 1.8 2.5 3.1 0.6
Seattle, WA 1.7 5.3 4.3 7.3 4.4 1.1 0.8 1.7 1.2 1.9 0.6
United States average 3.4 8.2 3.8 8.8 4.7 2.1 0.9 2.7 1.4 3.4 0.9

Notes:
The highest value for each measure is highlighted.
Rates are per 1,000 Medicare beneficiaries for inpatient surgical procedures occurring during the period 2008-10.
All rates were adjusted for age, race, and sex (when appropriate) using the U.S. Medicare population as the standard.
Blank cells indicate that there were not enough procedures performed in the HSA to produce statistically significant rates.
TURP and radical prostatectomy were restricted to males. Mastectomy was restricted to females.
View this table for 162 HSAs containing teaching hospitals.
Download Excel version of this table.


The rates of surgery for lower extremity bypass and radical prostatectomy are shown in Figures 5 and 6. In these charts, the 19 HSAs are displayed as red dots on a background of the 306 hospital referral regions (HRRs) throughout the nation. These charts demonstrate that the 19 HSAs studied reflect the national variation in care (but to a lesser extent, with many of the HSAs exhibiting rates close to or below the national average for many surgeries).

Figure 5. Lower extremity bypass per 1,000 Medicare enrollees (2008-10)

Figure 5

Figure 6. Radical prostatectomy per 1,000 male Medicare enrollees (2008-10)

Figure 6

arrow_left Data used in
this report
           Why is there variation
in surgery rates?
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The Dartmouth Atlas of Health Care is based at The Dartmouth Institute for Health Policy and Clinical Practice and is supported by a coalition of funders led by the Robert Wood Johnson Foundation, including the WellPoint Foundation, the United Health Foundation, the California HealthCare Foundation, and the Charles H. Hood Foundation.