We all know that good health has a lot to do with genes, nutrition, regular exercise and smart decisions like drinking alcohol only in moderation and not smoking. Except for the genetic part, much of the known formula for increasing your odds of a healthy life is within your control.
But did you know that there's another factor largely outside of your control that has a lot to do with whether you'll develop diabetes, how long you'll live and if you'll some day have a heart attack? This powerful factor also will help determine whether you'll be treated with drugs for heart disease, or undergo cardiac bypass surgery; how likely it is that you'll have a Cesarean section when you give birth; and if you'll have surgery for back pain.
That factor is geography, the accident of your birth -- or later, college, partner or career choice -- that lands you in Minnesota rather than Florida or California instead of Texas. Or even McAllen, Texas, rather than El Paso, Texas. Those are two cities 800 miles apart on the Texas-Mexico border and they have vastly different health expenditures and not so different medical outcomes. The two towns are similar in income and every other demographic. Atul Gawande, M.D. in the New Yorker highlighted them in a June 2009 article in which he showed that the average Medicare expenditure in 2006 per enrollee in McAllen was more than $15,000. Meantime, the town down the border road, El Paso, had expenditures in line with the national average, $7,504 -- or about half that of McAllen. And for twice the dollars, McAllen residents fared no better in their health outcomes than did folks in El Paso.
While those Texas towns represent extremes in cost differences, similar examples abound. Within the borders of the United States, precisely where you live has a lot to do with your health, your health care and what it costs.
The Dartmouth Atlas
A long-running study known as the Dartmouth Atlas of Healthcare has scrutinized Medicare data for two decades and found regional patterns in use of medical procedures and payments. Recently, the atlas' researchers have begun to detail regional statistics on pediatric patients and privately insured adults younger than 65.
A typical study from 2003, for example, showed that patients who had a hip fracture, heart attack or colon cancer requiring surgery in regions shown to use more than an average amount of medical care received up to 60 percent more care in the form of more frequent physician visits, more referrals to specialists, more tests and more minor procedures than patients in low-use regions. One example: a heart attack patient in Los Angeles could receive $7,000 worth of extra care over the course of a year as compared with a similar patient in Salem, Oregon. But what is astounding -- and relevant to health care reform -- is that the researchers concluded that all that extra money didn't result in longer or more functional lives. Patients in lower-cost regions did as well, and in some cases even better, than patients in higher-cost regions.
Much of the regional variation is attributable to the number of specialists in a given area and their collective culture of practice. Dartmouth researchers found, for example, that men older than 65 with early-stage prostate cancer who live in San Luis Obispo, Calif., are 12 times more likely than men from Albany, Ga., to undergo surgical prostate removal. Those with heart disease in Elyria, Ohio, were ten times more likely to have angioplasty or stent implantation than those in Honolulu. And women in Victoria, Texas, were seven times more likely to undergo mastectomy for early-stage breast cancer than women in Muncie, Ind. Yet the health and life expectancy of people in those higher-use regions did not prove better than for patients in lower-use regions. All the procedures just discussed, of course, have alternatives requiring less extreme surgery or none at all.
The data don't merely add up to facts to be dropped at a cocktail party: They make the case that physicians must talk to their patients about all medical options available, not just the one most comfortable for a practitioner.
What analysts for the Dartmouth Atlas find over and over again is that the more surgeons a region has, for example, the more surgery occurs; the more MRIs there are in an area, the more imaging occurs; the more hospital beds, the more likely it is that a patient will be hospitalized. And over and over, they find that while having more doctors, technology and hospitals costs more, it does not equal better results. In their hands, there consistently is, in fact, an inverse relationship between health care spending by state and scores measuring quality of care and outcome. Despite the conclusions from this highly regarded group, others have provided data that for some diseases like congestive heart failure, higher spending does result in better outcomes.
Science, Art and Physician Preference
Medicine largely is science, with a generous dash of art and a whole lot of geographic variation based on physician preferences even within the borders of a state. The California Healthcare Foundation has found that within the Golden State, doctors do things differently. Laguna Hills residents are 2.5 times as likely as Red Bluff Residents to get knee replacements; Berkeley women are 10 times more likely to deliver vaginally after a cesarean section than women who live in Hanford; Marysville residents are 2.5 times as likely as those living in Inglewood to undergo coronary artery bypass surgery.
All of those procedures have alternatives. Instead of a knee replacement, patients can try exercise and physical rehabilitation. Instead of vaginal birth after C-section, women can have another C-section. And instead of bypass surgery, heart patients might be treated with a drug regimen. Patients can be and are being steered in one direction or another and a lot of the direction depends on: how many orthopedic surgeons are in the area; how local ob-gyns want to manage the risks of vaginal birth after a C-section; and whether local cardiac care is influenced more by cardiac surgeons or by cardiologists who don't perform surgery.
Variations in regional medical practices persist, despite evidence that less aggressive treatments may be as effective as more invasive procedures. A recent study, for example, found that patients with stable coronary artery disease who received angioplasty and had a stent implanted did not live longer, nor did they have fewer heart attacks, than similar patients treated at far less cost with pharmaceuticals. And an analysis of many studies of treatment of low back pain without acute neurological dysfunction found that surgery had no greater long-term benefits than did intensive rehabilitation.
Geography and Lifestyle
It's not all about doctors and hospitals. A lot of what influences health happens outside of a doctor's office. Researchers at the University of Wisconsin Health Institute, supported by the Robert Wood Johnson Foundation, set about studying the health of people within every county in the U.S. Besides clinical care, researchers examined economic factors, physical environment and lifestyle behaviors.
What they found in updated research released in April was not good news. In 661 of more than 3,000 counties analyzed, life expectancy for women is declining. That means that baby girls born today in those counties are not expected to live as long as their mothers. Researchers also found wide disparities between U.S. counties -- as wide a health gap as seen between developed and developing nations around the world. For example, males in Marin County, Calif., live the longest of men in any county in the country. (Women in Marin come in second to women in Collier County, Fla.) What's shocking is the gap in longevity between the longest lived counties and the shortest. Women in Collier County, Fla., (85.8 years) live 11.7 years longer than women in McDowell, W. Va. (74.1 years); men in Marin County, Calif. (81.6 years) live a whopping 15.5 years longer than men in two counties of Mississippi, Quitman and Tunica (66.1 years).
And while we Americans like to think our health care is the best of the best in the world, Americans in 87 percent of U.S. counties don't live as long as folks in Cuba; in 22 percent of U.S. counties, Americans don't live as long as Syrians; and in 6 percent of U.S. counties, our citizens don't live as long as Iranians, according to Dr. Ali Mokdad, head of the research team that evaluated the county health statistics.
For rankings of California counties, click here. In our state, Marin County earns its high longevity rank with low rates of obesity, smoking, teen birth and sedentary lifestyle. Trinity County fares less well on those measures. Los Angeles County, ranking 28th out of 56, is smack dab in the middle.
Care based on proof; equal prevention opportunity
As the Dartmouth Atlas has shown, if we build it they will come -- to hospitals, to imaging labs, to surgical suites. Of course, we need to provide sufficient doctors, hospitals and technology. But for cardiac surgery and back pain treatment and other such medical therapies, we should be guided by fact-based, scientific evidence from research, not physician preference or the number of empty hospital beds that need filling.
My colleagues in medicine, as well as law- and policy-makers and all of us as ordinary consumers and patients, as I've said before, must act urgently so that the runaway costs in health care don't lead to the collapse of our health system. The writing is on the wall -- or in this case, in superb and increasingly voluminous research. We must stop letting profit and practice habits that are unsupported by evidence drive us or we will see ever more inequitable, unsustainable and unhappy health-related consequences for ourselves and for society.
And taking a hard, objective look at the lifestyle-related health consequences in specific regions, as is occurring with the county health rankings, can help local officials decide where to concentrate preventive efforts: more playgrounds, for example, or increased stop-smoking campaigns. Researchers report that some communities are starting to make changes based on the survey results. These efforts need to pick up their pace if all of our children are to enjoy long and healthy lives.