THURSDAY, Oct. 7, 2004 (HealthDayNews) -- Wide variations exist in hospital care and treatment results for chronically ill Medicare patients.
In addition, hospitals deemed "the best" by U.S. News and World Report may not actually be the best, according to a group of Dartmouth Medical School studies appearing in the Oct. 7 Web edition of Health Affairs.
"The papers document the impact of variation that are unexplained by illness, patient preference, or the dictates of evidence-based medicine," John Iglehart, founding editor of Health Affairs, said Thursday at a news conference to announce the findings. "Until the public grasps their implications, progress on reducing them will be limited."
"The results have very real consequences for all of us," added Leonard Schaeffer, chairman and CEO of Wellpoint Health Networks. "More care is not better and, in some cases, may have hastened death." The Wellpoint Foundation funded this issue of the journal.
Dr. John Wennberg, director of the Center for Evaluative Clinical Sciences at Dartmouth Medical School, first started collecting evidence on variations in health care in the United States 31 years ago. He co-authored a landmark paper that was published in Science in 1973 and has continued probing the problem ever since.
"We have been concerned with the quality of decision-making associated with variations we see around the country," Wennberg said. "Per-capita expenditures in Miami are twice that of Minnesota, and procedure costs are not the explanation."
Indeed, the variations revealed by these papers are striking and widespread.
A paper for which Wennberg was the lead author found that the seven hospitals leading U.S. News & World Report's 2001 rankings for geriatric care had quite different levels of care. For instance, Medicare patients who were cared for by Mount Sinai Medical Center in New York City during the last six months of their lives spent almost twice as many days in the hospital than did patients at Mayo Clinic hospitals. The number of days spent in the intensive care unit (ICU) was three times higher for Medicare patients at UCLA Medical Center than at Massachusetts General Hospital in Boston. Mount Sinai and UCLA patients had twice as many physician visits as Duke University Hospital in North Carolina.
Care during a terminal illness also differed. Medicare beneficiaries cared for at St. Louis University Hospital were almost 70 percent more likely to spend time in the ICU than those at Mayo Clinic hospitals. Hospice use was 2.5 times greater among Johns Hopkins Medicare patients than Mount Sinai patients. Also, the number of patients who actually died in a hospital ranged from 32 to 52 percent, depending on the facility.
Another paper found that academic medical centers differed by up to 60 percent in the overall "intensity" of medical services offered to Medicare patients who had had heart attacks or hip fractures or who were suffering from colorectal cancer. Total days spent in the hospital were 16 percent to 38 percent higher in the highest intensity vs. lowest intensity centers. Use of imaging was 20 percent to 26 percent higher, and diagnostic testing 73 percent to 94 percent higher in the high-intensity facilities.
This seemed consistent with previous research, which had found that patients with chronic conditions received twice as much hospital-based care over a three-year period at Boston University Medical Center as similar patients at Yale-New Haven Hospital. Recent studies have also shown that Medicare beneficiaries at New York University (NYU) Medical Center spent almost three times as many days in the hospital (27) as patients at Stanford University Medical Center (10) in California. NYU patients also had more than three times as many physician visits (76 vs. 23).
Another paper found variations in care offered to different racial and ethnic groups. White patients, for instance, got almost three times as many carotid endarterectomies -- a surgery that cleans the main arteries feeding the brain -- and 30 percent more angiograms as black patients. Blacks also had higher rates of admission to the ICU in the last six months of life.
Blacks also received different care depending on their geography. HbA1c testing (for people with diabetes) was nearly equivalent in blacks and whites in Columbia, S.C., and in the Bronx, N.Y., but radically different in Durham, N.C., and East Long Island, N.Y.
In addition, blacks had rates more than 40 percent lower than whites for hip replacement surgery, but the rates were more equitable in Raleigh, N.C., (22 percent lower than whites) than in Manhattan (74 percent lower) .
Overall, the authors wrote, "Black Medicare beneficiaries have higher health-care spending but are less likely to get many treatments."
"There's a tremendous amount of opportunity to improve quality and reduce costs," said Dr. Mark McClellan, administrator of the federal Centers for Medicare and Medicaid Services. "The study shows us more clearly than ever that higher costs don't necessarily mean higher quality. Medicare is spending 30 percent more than it needs to be. Even at these high costs, there are major gaps in health-care quality and safety."
Beneficiaries need to be more involved in their own care, McClellan stated, if costs are to come down and quality remain consistently high.
More information
View all the articles at Health Affairs.
