A patient’s odds of undergoing surgery often depends more on where he or she lives than on their clinical circumstances, according to a two-part series exploring variation in surgery use, published in The Lancet.

In the first part of the series, University of Michigan surgeon John Birkmeyer and colleagues suggest regional variation in the use of surgical procedures exists in many different countries, yet patient demand and differences in diagnostic practices do not appear to have much of an effect on these differences. Instead, Birkmeyer cautions that the motivations and beliefs of doctors are the most important reasons for surgical variation.

"Better scientific evidence about the comparative effectiveness of surgical and non-surgical interventions could help to mitigate regional variation," the researchers concluded, "but broader dissemination of shared decision aids will be essential to reduce variation in preference-sensitive disorders."

In the second series paper, physicians at John Radcliffe Hospital, Oxford, U.K., examine in detail strategies to reduce regional variation in the provision of surgery, arguing that addressing unwarranted regional variation could have enormous potential to reduce avoidable deaths and illness, as well as unnecessary use of resources. These authors suggest that variation in surgical provision needs to be more widely recognized, and its causes better understood.

Although existing lack of evidence makes the evaluation of different approaches to reducing variation difficult, the authors, led by Radcliffe’s Peter McCullough, advise that while some system-level changes – especially changes to funding structure – can have major effects on the use of surgery, these changes can be difficult to control, and may even reduce the quality of care.

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