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Seniors living in Manhattan spend an average of nearly 25 days a year at doctor visits or at a hospital. But in Lebanon, New Hampshire, contact with the healthcare system is far lower - just 10 days on average.

New Yorkers probably are not that much sicker than their New England neighbors. Instead, the statistic reflects the wide variation in the way healthcare is delivered to older adults around the United States.

The Dartmouth Institute for Health Policy and Clinical Practice recently issued a report card on how the United States provides healthcare to seniors by region. Using Medicare enrollment and claims data from 2012, the report compares regions on such factors as where seniors spend the most time with doctors, where they are most likely to be hospitalized, or be subjected to unnecessary tests or risky medications.

The report also points to ways seniors - or children helping to care for elderly parents - can navigate the healthcare system to receive better care. The research is being used to discover whether best practices are being used - and where. The answers vary widely across the country.

Consider the following high and low measurements:

* In York, Pennsylvania, 73.4% of seniors had a primary care physician as their predominant healthcare provider who coordinated all their care, compared with just 42.6% in Metairie, Louisiana. The national average was 56.9%.

Research has shown that regions with a greater proportion of care provided by primary care physicians tended to have lower costs, higher quality, and lower rates of avoidable hospitalizations.

* In Clearwater, Florida, 26.1% of seniors had an annual wellness checkup, compared with just 1.2% in Meridian, Mississippi. Under the Affordable Care Act, all Medicare enrollees are entitled to a free annual preventive check-up, which includes personalized prevention planning, an assessment of a patient's functional ability and a review of a person's risk factors for depression.

Nationally, just 10.7% of Medicare beneficiaries took advantage of the wellness visit in 2012 - a number that should be far higher.

* In Fort Lauderdale, Florida, patients saw an average of 4.7 clinicians in 2012, compared with just 2.4 in Bangor, Maine (the national average was 3.4). Here, less is more - it is a measure of the complexity and fragmentation of care a beneficiary is receiving. More providers translates into greater rates of overuse and misuse of care, duplication of services and higher risk of communication-related risks and errors, according to the report.

* 30% of male seniors over age 75 in Miami were screened for prostate cancer, despite a 2008 recommendation by the U.S. Preventive Services Task Force that the test not be done on men above that age. In Casper, Wyoming, the rate is 9.9% (U.S. average: 19.5%.)

Current best-practice thinking is that benefits of the screening do not outweigh the harms, including patient worry about false-positive results, invasive follow-up tests and treatment with side effects.

* The practice of placing a feeding tube in patients with advanced dementia has been widely discredited as not prolonging life or improving outcomes, yet it happened in 14.2% of cases in Lake Charles, Louisiana, in 2012. In Portland, Oregon, just 1.3% of patients received a feeding tube, and the national average was 6%.

The wide variation in these numbers points to a need for more coordination of care through primary care physicians with expertise caring for elderly patients, said Dr. Julie P.W. Bynum, associate professor at the Geisel School of Medicine at Dartmouth College and the report's lead author.

"As you age, you have lots of different medical problems competing against one another," she said. "Having someone who can coordinate all the different doctors is important. If you have two or three diseases, you want the whole person treated."

If you are not sure your doctor is playing that role, Bynum recommends that you ask her a simple question: "Are you the doctor to whom I should have all my records sent? Do all the records come to your office?"

Bynum also urges patients and their families to assert themselves more when it comes to healthcare decision-making. And if you feel like healthcare is eating up too much of your time, ask your doctor is there is a way to schedule things more efficiently, she adds. "Can you get your lab tests done one day a year instead of six?"

Finally, Bynum offers a reminder about annual wellness checkups. "It's a new benefit - so it's important to know that you can ask for it."


For information on the healthcare system's performance where you live, visit this interactive map produced by the Dartmouth Institute. A good free guide on how to talk with your doctor is available from the National Institute of Aging. The Health in Aging Foundation offers guidance on medications that elderly patients should avoid.