For three decades, researchers at Dartmouth have tracked wide geographic variations in treatment patterns across the country, focusing primarily on the underuse of types of care proven to be effective. More recently, the team shifted its attention to potential overuse of care. The reports published yesterday are the first to analyze treatment patterns at specific hospitals.
In the first report, Wennberg examined the Medicare records of 90,600 patients during the last six months of life in 77 well-regarded teaching hospitals. He compared frequency of doctor visits and hospitalizations and time in the intensive care unit for people with solid tumor cancers, congestive heart failure and chronic lung disease.
He found dramatic variations in the amount of care given to patients with the same maladies. Patients at New York's Mount Sinai Medical Center, for instance, spent almost twice as many days in the hospital as those in the Mayo Clinic's St. Marys Hospital in Rochester, Minn.
The number of terminally ill patients who died in the hospital, rather than at home or in hospice, ranged from 32 percent to 52 percent, despite surveys that indicate most Americans prefer not to die in a hospital.
"If you can get the same benefits for patients with lower intensity use, then you have a more efficient system in which to provide that care" said Ralph Horwitz, dean of Case Western Reserve University School of Medicine in Cleveland. He said the studies were valuable, because for too long "we have substituted volume for a measure of quality."
Yet practicing physicians are often frustrated by attempts to measure quality because they overlook what doctors "take the most pride in: to make countless daily decisions about diagnosis and treatment using copious, incomplete, confusing and changing information, under time pressure and in the face of an ambiguous medical literature," wrote Harvard Medical School professor David Blumenthal.
Fisher's analysis tracked mortality rates for Medicare patients in 300 hospitals for heart attacks, colorectal cancer or hip fractures. After devising five categories based on "intensity" of care, he found that "high-intensity" institutions spent vastly more money -- on X-rays, specialist visits, inpatient care and follow-up -- than the "low-intensity" hospitals. But the high-end hospitals are "not doing a better job on quality," he said.
Robert Dickler, senior vice president of health care affairs at the Association of American Medical Colleges, said the reasons for variations may vary, noting that some hospitals may keep patients longer simply because there is no bed available at a skilled nursing home. Still, he expects teaching hospitals to use the reports to improve care and efficiency.
The Health Affairs issue was underwritten by the WellPoint Foundation, a charitable arm of the California-based health insurer. Chief executive Leonard Schaeffer said the articles should serve as a wake-up call.
"In the current system, poor quality pays," he said. "Physicians are reimbursed for both incorrect treatment and effective therapy."
