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The use of common surgical procedures varies widely across geographical regions. Differences in illness burden, diagnostic practices, and patient attitudes about medical intervention explain regional variation in surgery rates to only a small degree. Instead, current evidence suggests that surgical variation primarily reflects differences in physician beliefs about the indications for surgery and the extent to which patient preferences are incorporated into treatment decisions. These two components of clinical decision making help explain the “surgical signatures” of specific procedures, as well as why some consistently vary more than others. Variation in clinical decision making is in turn influenced by broader environmental factors, including technology diffusion, specialist supply and local training paradigms, financial incentives, and regulatory factors, which vary across countries. Better scientific evidence about the comparative effectiveness of surgical and non-surgical interventions may help mitigate regional variation, but broader dissemination of shared decision making tools will be essential in reducing variation with preference-sensitive conditions.

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