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When It Comes to Health Care, Less Can Be More

Survival rates unaffected by drop in veterans' hospital visits

WEDNESDAY, Oct. 22, 2003 (HealthDayNews) -- It's a common belief that when it comes to your health care, the more services you can get, the better.

But a new study questions that popular assumption.

Researchers from the Houston Veterans Affairs Medical Center report that despite a drastic reduction in inpatient hospital stays and urgent care visits, survival rates for veterans with chronic physical and mental illnesses stayed mostly unchanged while the use of primary-care services increased only modestly.

The drop in hospital rates was a result of a reorganization of the Veterans Affairs (VA) health care system that began in 1995 with the goal of shifting from a hospital-based health system to one that focused more on primary, outpatient care.

"Hospital use dropped by about half," says study author Dr. Carol Ashton, director of the Houston Center for Quality of Care and Utilization Studies and chief of general medicine at the VA Medical Center in Houston.

"I was surprised at the magnitude of the drop in hospital use. It was much more extensive than I would have expected. I wasn't surprised at the survival rate, however. I think the VA was using more hospital care than it needed to at the time."

The study appears in the Oct. 23 issue of The New England Journal of Medicine.

Ashton and her colleagues looked at data from more than 342,000 VA beneficiaries who had one of the following chronic illnesses: chronic obstructive pulmonary disease; pneumonia; congestive heart failure; angina; diabetes; chronic renal failure; bipolar disorder; major depression; and schizophrenia.

Between 1994 and 1998, the researchers tracked the number of in-patient hospital stays, urgent care visits, use of primary-care services, death rates and the use of non-VA medical services.

For the five-year period included in the study, the researchers found a 50 percent reduction in hospital usage and a 35 percent drop in urgent care visits. At the same time, the use of medical clinics only went up about 10 percent. Also, the researchers found there wasn't a great increase in the use of non-VA hospitals by Medicare-eligible veterans.

Despite the decline in hospital and urgent care use, survival rates remained nearly unchanged.

Ashton says one reason that survival rates remained essentially the same despite the hospital cutbacks was that the VA was using more hospital services than it needed to. Also, she says, the reorganization focused on providing primary services, letting physicians give veterans more preventative care.

Dr. Elliott Fisher, a professor of medicine at Dartmouth Medical School in Hanover, N.H., who wrote an editorial about the study in the same issue of the journal, says the study shows "more care isn't necessarily better for you."

Fisher says this study is important because it's one of the few that has looked at the outcome of health-care changes.

"Many changes are introduced and never evaluated," says Fisher. "Little research is done on the management of chronic diseases and whether or not hospitalization is the best way to manage those diseases. We need better information on the risks and benefits of treatments."

Fisher says that while this study was done on a VA population, the results may be applicable to the general population. He points out that per capita health-care spending in 2000 exceeded $10,000 in New York City, while it was less than half that for someone in Portland, Ore.

Yet, he says, outcomes aren't drastically different, and may even be worse for someone who has unnecessary health-care treatments.

"When you have patients with severe chronic illness, it's often easier to manage them in the hospital, and we think it's safer, but what this study suggests is that assumption is worth questioning," says Fisher.

More information

For tips on managing chronic illness, visit The National Women's Health Information Center or the Cleveland Clinic.

SOURCES: Carol Ashton, M.D., M.P.H., director, Houston Center for Quality of Care and Utilization Studies, chief, general medicine, VA Medical Center, Houston, and professor, medicine, Baylor College of Medicine, Houston; Elliott Fisher, M.D., M.P.H., professor, medicine and community and family medicine, Dartmouth Medical School, Hanover, N.H.; Oct. 23, 2003, New England Journal of Medicine
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