Where you live determines your quality of care

The Midwest
The states: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin

Knee surgery rates double
People here are prone to knee replacements, according to 2005 Medicare data. The rate in Nebraska was 50 percent higher than the national average — more than double the rate in much of the Northeast. The phenomenon may be partly explained by the greater number of overweight people, who tend to have more knee problems. But Dr. Ronald P. Grelsamer, an orthopedic surgeon and author of several books on knee surgery, suggests that because of the distances Midwestern patients must sometimes travel, physicians may be quicker to offer end-stage treatment when a less invasive one — such as occasional injections — might do the trick. "With knee replacement, it's a matter of how long a person wants to tough it out before accepting the risks of surgery," he says. That's a decision for the patient, he adds — not the doctor.

Less help for obesity
Midwestern states, along with the South, have the highest rates of morbid obesity in the country — more than 4 percent of women in their 50s weigh so much that they're at greatly increased risk of heart disease and other deadly ills. For them, weight loss surgery can be lifesaving, says Dr. Benjamin Poulose. But in a 2005 study at Vanderbilt University, he and his colleagues found those regions had the lowest rates of the surgery: A Midwestern or Southern candidate for the surgery was just 25 percent to 50 percent as likely to get it as if she lived in the Northeast.

Hot spot
Elyria, Ohio: Sky-high angioplasty rates

For years, the city of Elyria has had the nation's highest rate of angioplasty, a heart treatment that involves threading a balloon catheter through a blocked artery. Local statistics have stood out since at least 1996, according to Dartmouth researchers; by 2003, the city had 42 procedures per 1,000 Medicare enrollees, compared with just 11.3 per 1,000 in the rest of the nation. A cardiologist's decision to perform angioplasty instead of treating with drugs (or suggesting bypass surgery) is a judgment call in most cases, and the Dartmouth experts say whenever there's that kind of uncertainty, a physician practice or hospital can become wedded to a single approach to the problem.

4 keys to great health care 1. Find a doc you trust — and who listens. If your physician treats you like a customer at a drive-thru or makes you feel foolish for asking questions, get another doctor. Experts say one of the best ways to protect yourself is to find a physician who will take time to talk over a procedure's risks and benefits and listen to your personal concerns. 2. Explore the do-nothing option. "If a doctor recommends an invasive treatment, such as hysterectomy or knee surgery, you should ask a series of questions," advises Shannon Brownlee, author of "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer." "Ask: Is there a less invasive treatment I can try first? What's the evidence this treatment will leave me better off than I am now? How good is the evidence? What's likely to happen if I don't do anything?" Query tests, too. Experts know tests can reveal an abnormality that may never cause a problem — but once a little abnormality is found, it's hard for a doctor (or a patient) to do nothing. 3. Find a second opinion outside your community. If your condition is serious (or can be treated multiple ways), it's worth traveling across town to a doctor affiliated with a different hospital — or perhaps even to another state to see a doctor there. Or get another point of view without hitting the road by trying a reputable online service that offers second opinions, such as MyConsult, run by the Cleveland Clinic. (The cost of online second opinions may not be covered by your insurance.) 4. Seek decision-making tools. Many medical choices have no obvious right or wrong answer, only ones that work better or worse for you. In the case of breast cancer, for instance, one woman might prefer to preserve her breast — even though she'll have to be alert to the possibility of the tumor recurring — while another woman might choose to have a mastectomy. At decisionaid.ohri.ca/decguide.html, you can access worksheets used by the Center for Shared Decision Making to figure out what matters most to you.

The Northeast
The states: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont

Women get better care
Northeastern women get more frequent Pap tests and mammograms than women who live elsewhere in the country. States in the Northeast tend to have patient-friendly policies — ones that boost the number of women with health insurance, for example, or make it easier for workers to take time off to help a family member with medical problems. The result: The region (especially New England) is a good place for women to live, according to a report by the National Women's Law Center and Oregon Health & Science University, which rated states on nearly 100 factors. "They've put resources into improving the health of their populace, and that pays off," says Dr. Michelle Berlin, an author of the report.

Patients spend an extra 16 percent 
Northeasterners tend to see more doctors (including pricey specialists) and get more tests than people in other parts of the country, and they feel it in the pocketbook. Annual costs per person totaled $6,171 in the Northeast in 2004, compared with a national average of $5,283, according to a report by the Centers for Medicare & Medicaid Services. But that extra care isn't necessarily a good thing, says Dr. Elliott Fisher, a researcher at the Dartmouth Institute. In a 2006 study, patients who saw appreciably more doctors were actually slightly more likely to die, probably because of complications that can accompany procedures, and similar factors. Surprisingly, says Fisher, "the evidence suggests that higher spending is actually associated with lower quality."

Breast cancer surgery may be less invasive
Although numerous studies have shown virtually equal survival rates for women who get breast-conserving lumpectomy versus those who have a mastectomy, treatment varies significantly from state to state. In a 2006 study at the University of Louisville, 71 percent of breast cancer patients in the Northeast had a lumpectomy, compared with just 63 percent of women in the Southeast. How a doctor presents the options can tilt a woman's decision, says Dr. E. Dale Collins, medical director of the comprehensive breast program at Dartmouth-Hitchcock Medical Center. So can other factors, like how easy or difficult it is to get follow-up care. Most lumpectomy patients need multiple radiation treatments, she points out, and in some other areas of the country, you might have to drive 2 hours a day to get it. "That might change your treatment choice," she says.

Hot spot
Newark, NJ: Over-hospitalization

Most people hope to spend their final days at home or in a hospice, but in this city, nearly 50 percent of elderly patients die in a hospital, the most expensive and impersonal way to go. It's the highest rate in the country, according to a review of Medicare data from the mid-1990s. (In Bend, OR, where rates are among the lowest in the United States, fewer than 20 percent of Medicare deaths were in a hospital.) One possible reason: Newark has a lot of hospital beds for a town of its size — and studies show that can affect doctors' behavior. "The more hospital beds there are, the more likely a person will be hospitalized rather than treated at home," says Fisher. "It's easier for the physician, but it's not always best for the patient."

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