A similar story unfolds with stable angina. Patients so diagnosed have the option to be treated with medications and lifestyle change or with medications, stenting, or surgery.
But there is a trade-off. Stenting and surgery carry their own short-term risks, such as stroke, heart attack, and death. Yet in Elyria Ohio, beneficiaries are 10 times more likely to undergo percutaneous coronary intervention than those in Honolulu. And patients in McAllen, TX are four times more likely to undergo a coronary artery bypass graft procedure than those in Pueblo, CO.
The latest Atlas report documents variation for 306 hospital referral regions, and about 3,000 residential zip code regions.
For Brownlee, the variation boils down to questions of ethics about how much physicians are fully informing their patients. "The reason to be concerned about shared decision making is because it's the right thing to do. We have to make sure patients are really fully informed about their options, and that they get to choose the elective procedure that's the right one for them. At its very heart, it's an ethical issue."
I think the latest Atlas tome has it right. The decision on course of care should be one that doctors make with a patient or the family. The days when doctors tell patients "This is what we're going to do for you..." without explaining the options, should be over.
Wexler sums up that there are two underlying ethical principles at work in the delivery of care. One is the duty of the physician to do what the physician believes is in the best interest for the patient. But the second is to respect that the individual has a right to say what will happen to his or her body. "We have an ethical obligation to respect that autonomy ... But we have allowed habit, bias, and financial incentives to creep into this equation."