As the scope and quality of surgical care continue to advance, there is still much that remains to be done to optimize care for patients. For many conditions, surgery is one of several care options, and in some instances, there are several types of surgical procedures available. Research into the effectiveness and adverse effects of a surgical procedure compared to alternatives are often incomplete. While quality has generally improved over time, outcomes can differ across hospitals and surgeons. Too often, treatment options, whether medical or surgical, are recommended without patients fully understanding the choices and participating in the decision; and these recommendations can vary markedly from one physician to the next. The best strategies to achieve these goals are the focus of quality improvement groups in consideration of the various treatment options available. The outcomes data being recorded should go a long way toward producing the kind of widely applicable data upon which patient decision support tools should be based. This Dartmouth Atlas of Health Care series reports on unwarranted regional variation in the care of several conditions for which surgery is one important treatment option.
Finally, the costs of care continue to rise and often differ across health care systems, even the most reputable and prestigious. Why can the “best” surgical care at one academic medical center cost twice as much as another? The next section is concerned with the care of patients after surgery, including hospital re-admissions and ambulatory care.
Patients with diabetes (high blood sugar) and peripheral arterial disease (PAD, or blockages in the arteries of the legs and other locations) are at high risk for major limb amputation at rates several times the national average for patients without diabetes. Nearly 100,000 major leg amputations are performed annually in Medicare patients, and more than half of them occur as a result of diabetes. Co-occurrence of these two illnesses—diabetes and peripheral arterial disease—has a negative synergistic effect, leaving patients at a higher risk for amputation than either of the two diseases alone.
This report reveals significant variation in the approaches to the treatment of diabetes and PAD chosen by patients and physicians. These differences are striking, not only for preventive treatments but also in the use of invasive treatments designed to limit the devastating effects of these diseases. Depending on a variety of influential factors—race, the part of the country in which they live, as well as the choices made by the physicians caring for them—patients may or may not receive important preventive care.
These efforts are needed most and will have the greatest impact, in the regions of the United States where the amputation risk is the highest. There are many regions where amputation is common, such as the rural southeastern states. In these regions, especially among black patients, the risk of amputation is several times higher than in nearly all other regions of the country. This report suggests that, while a comprehensive approach is necessary, focusing on black patients in poor, rural regions of the United States is likely to be the best place to start. This approach will have the most impact—and likely the greatest challenge towards implementation—as high limb loss rates have been a part of life for many years in rural portions of the southern United States.