Researchers even found that hospitals deemed the best in the U.S. for geriatric health care routinely provide elderly patients with treatment that widely differs from other top hospitals on the list. Analysts say they are largely at a loss to explain the variability in care but that it is a sign of widespread waste and inefficiency in the U.S. hospital care system.
"No matter how preeminent the institution, care varies all over the ballpark," says John E. Wennberg, MD, director of the Center for Evaluative Clinical Sciences at Dartmouth University, who authored one of several studies released Thursday by the journal Health Affairs.
He and other researchers tracked Medicare billing data for 90,600 elderly patients suffering from chronic diseases — cancer, heart failure, and lung disease — who got health care at one of 77 hospitals listed as "best" on a 2001 list of top geriatric centers by the magazine U.S. News & World Report. Their study concluded that doctors at some hospitals treated terminally ill patients more intensively than they do at others.
For example, patients using New York University Medical Center received an average of 76 doctor visits in their last six months of life compared with an average of 54 visits for similarly ill patients at nearby Mount Sinai Hospital. Meanwhile, similar patients at Stanford University Hospital outside of San Francisco saw doctors for health care just 27 times in six months on average.
Wennberg reported comparable differences in the number of days spent in the hospital and on the amount of money hospitals charge Medicare for health care.
Researchers have long known that care patterns vary between different regions of the country, but researchers say they are struck by the size of differences between hospitals since the study controlled for factors such as patient age and severity of disease.
Quality of Health Care No Different
All of the extra attention and spending at the most active hospitals frequently does not translate to better health care. Another study that tracked care at 300 teaching hospitals found that patients fared no better at the most treatment-intense centers, and in some cases had worse results.
Elderly patients' five-year survival rates after hip fractures were no different between higher-intensity and lower-intensity hospitals, while patients with heart attacks and colon cancers actually had slightly worse survival rates at more intense facilities, according to Elliott S. Fisher, MD, another Dartmouth researcher.
Analysts try to explain the results by pointing to widely varying cultures between teaching hospitals. Some facilities may opt for lots of tests and procedures in an effort to find cures, while others take a more relaxed approach to health care.
The trouble is that more treatment does not necessarily mean better health care, and few studies exist to explain which approach is best.
"If these academic medical centers are so different, where is the science governing decision making?" Wennberg says. "There's basically no medical evidence about how frequently one should be hospitalized," he notes.
Medicare chief Mark B. McClellan tells reporters that his agency is launching projects aimed at tying the program's doctor and hospital payments to actual improvements in health care quality. The projects are expected to roll out as the agency implements the updated Medicare statute signed into law in January.
"Medicare spending may be 35 percent higher than it needs to be," McClellan says.
SOURCES: Health Affairs Web Exclusive on care variability, Oct. 7, 2004. Health Affairs web site. John E. Wennberg, MD, director, Center for Evaluative Clinical Sciences at Dartmouth Medical School. Elliott S. Fisher, MD, professor of medicine, Center for Evaluative Clinical Sciences, Dartmouth Medical School. Mark B. McClellan, MD, administrator, Centers for Medicare and Medicaid Services.
By Todd Zwillich
Reviewed by Brunilda Nazario, MD
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