3 p.m., ET, Thursday, October 7, 2004

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Janet Firshein, Linda Loranger, and Kari Root

Jon Gardner
Health Affairs

Dartmouth Studies Show Wide Variations In Hospital Care
And Outcomes For Chronically Ill Medicare Patients

Study Questions Performance of Leading Hospitals
Deemed “The Best” by U.S. News & World Report

BETHESDA, MD – Medicare patients with similar chronic conditions receive strikingly different care, even among hospitals identified as “best” for geriatric care by the magazine U.S. News & World Report, according to Dartmouth Medical School studies released today. The studies, featured in the October 7 Web-Exclusive edition of the journal Health Affairs, show that the frequency of physician visits, the number of diagnostic tests, and rate of hospital and intensive care unit (ICU) stays vary markedly. The studies, at http://content.healthaffairs.org/cgi/content/full/hlthaff.var.5/DC1, show that a higher intensity of care and higher level of spending are not associated with better quality or longer survival times even in the most renowned teaching hospitals.

In fact, there is evidence that a very high intensity of care for people with certain terminal medical conditions might hasten death, the researchers report. New findings identify, by hospital, where Medicare enrollees are receiving much more intensive care for common medical conditions, raising questions about usual methods of identifying “best” hospitals.

The October 7 Web edition of Health Affairs, funded by the WellPoint Foundation, features 20 articles and analyses on medical practice variation by some of the nation’s leading health care experts, including John E. Wennberg, MD, MPH, who directs the Center for the Evaluative Clinical Sciences at Dartmouth Medical School in Hanover, NH. The studies were released today at a Washington, DC briefing, sponsored by The Robert Wood Johnson Foundation, which funds the Dartmouth Atlas of Health Care project.

Wennberg, the principal investigator and series editor of the Dartmouth Atlas, has documented significant geographic variations in medical practice since the early 1970s. He says the significance of these findings is that “for the first time we can use Medicare claims data to measure the performance of individual hospitals and identify those hospitals that appear to be doing a better job managing chronic illness and patient care.”

The studies prove that “no matter how preeminent the institution, the care varies all over the ballpark,” Wennberg says. “It is clear that quality is inversely correlated with the intensity of care and that the better hospitals are using fewer resources and providing fewer hospitalizations and physician visits.”

“Because these studies focus on specific providers rather than specific communities, they will advance our understanding of variations in how hospitals deliver care to people at the end of life. Now, hospital quality can be measured with concrete data on experience rather than perceived reputation,” says James Knickman, Ph.D., vice president of research and evaluation at The Robert Wood Johnson Foundation.

"This research should serve as a wake-up call to all health plans that we have a collective responsibility to drive quality and cost transparency in medical care," said Leonard D. Schaeffer, chairman and CEO of WellPoint Health Networks, Inc. "Health plans must intensify their efforts to integrate the data they are capturing everyday and turn it into information that transforms the American health care system."

Hospital Care During the Last Six Months of Life

In the first study, Wennberg and colleagues evaluated the efficiency of 77 hospitals deemed “best” for geriatric care and heart and pulmonary disease in managing chronically ill Medicare patients during the last six months of life. The authors looked at variations in care for more than 90,616 patients age 65 and older suffering from solid tumor cancers, congestive heart failure, and chronic obstructive pulmonary disease, comparing the illness-adjusted frequency of physician visits, hospitalizations, and ICU stays.

The authors also profiled the use of care and medical resources for patients treated in seven teaching hospitals ranked by U.S. News & World Report in 2001 as the top geriatric institutions in the country.

They found striking variations in the amount of care provided with no association between higher intensity of interventions and better outcomes. Highlights of what they found:

– Patients receiving care from New York’s Mount Sinai Medical Center spent almost twice as many days in the hospital as patients treated at the Mayo Clinic’s St. Mary’s Hospital in Rochester, MN.

– ICU days for patients at the University of California, Los Angeles (UCLA) Medical Center were three times greater than for ICU patients treated at Massachusetts General Hospital in Boston.

– Mount Sinai Medical Center and UCLA patients had twice as many visits from physicians as patients treated at Duke University Hospital in North Carolina.

The quality of care for those with terminal illnesses also varied widely. The number of patients who died as hospital inpatients, rather than at home or in hospice, varied from 32 percent of all deaths to more than 52 percent, despite the fact that the vast majority of Americans say they would rather not be in the hospital at the time of death.

For example, patients assigned to the St. Louis University Hospital were almost 70 percent more likely to spend time in intensive care during the hospitalization in which they died than were people who died as inpatients at Mayo Clinic hospitals.

Academic medical centers (AMCs) ranked at the top of U.S. News’ list for geriatric care also differed in number of different physicians who cared for patients during their last six months of life. The number of physicians responsible for managing chronic illness ranged from 12 per 1,000 decedents at Duke University and the Mayo Clinic, to 20 and 22 per 1,000 decedents at UCLA and Mount Sinai.

Patients at UCLA and Duke also were less likely to see a primary care physician than patients at St. Louis University or Mount Sinai Medical Center. Patients at UCLA had 2.8 times more visits with specialist physicians than with primary care physicians.

Higher Intensity Does Not Lead To Better Care

A complementary study, at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.var.19, coauthored by Elliott Fisher, MD, Dartmouth professor of medicine and of community and family medicine, looked at patients who received their initial hospitalization for one of three reasons — heart attack, colorectal cancer, and hip fracture — in one of 299 hospitals that belong to the Council of Teaching Hospitals.

Fisher and colleagues examined patterns of practice, quality of care, and health outcomes in teaching hospitals. In fact, they found that the overall intensity of medical services delivered to patients with serious chronic illnesses varied by up to 60 percent.

Their conclusions: patients in the highest-intensity hospitals spend more time in the hospital and ICU; have more frequent physician visits in the inpatient setting; have more specialists involved in their care; and receive more imaging services, diagnostic testing, and minor procedures.

The authors also examined long-term mortality rates for patients cared for in hospitals of differing intensity levels and found no association between higher intensity of care and improved survival. Among hip fracture patients, there were no significant differences in death rates across groups. Among heart attack and colorectal cancer patients, there actually “was a small but statistically significant increase in the risk of death as intensity increased.”

Specifically, after an acute episode, Medicare reimbursements for hospital and physician services was 47–58 percent higher in the high-intensity teaching hospitals (which included New York University Medical Center; Cedars-Sinai Medical Center in Los Angeles; and Jackson Memorial Hospital in Miami) compared with the lowest-intensity hospitals (which included Mayo Clinic affiliate St. Mary’s; Strong Memorial Hospital in Rochester, NY; and Richland Memorial Hospital in South Carolina.)

Compared to the low-intensity group, in the highest-intensity group:

• Use of evaluation and management services was 56 percent to 82 percent higher;
• Diagnostic imaging was 20 to 26 percent higher;
• Diagnostic testing was 73 to 94 percent higher;
• Rates of hospital visits and new specialist consultations were about twice as high.

What Remedies Exist?

Although Wennberg says medical practice variation is “remarkably resistant to change,” he believes there are steps the private and public sectors can take to begin to reduce disparities, such as rewarding providers for efficient, high-quality performance. A provision in the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 that creates a demonstration to test out this idea is a giant step in the direction of addressing unwarranted variation in health care, he says.

Health Affairs, published by Project HOPE, is a bimonthly multidisciplinary journal devoted to publishing the leading edge in health policy thought and research. Copies of the October 7, 2004 Web-Exclusive articles on medical practice variation will be available on-line until October 22, 2004, at www.healthaffairs.org. Address inquiries to Jon Gardner, Health Affairs, at 301/347-3930, or via e-mail, jgardner@projecthope.org.


©2004 Project HOPE–The People-to-People Health Foundation, Inc.