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Quality of care varies, even at top hosptials

Quality Improvement Monitor, October 15, 2004

Medicare patients who have similar chronic conditions receive very different care with very different costs--with little difference in outcomes or survival--even at the nation's top hospitals, according to a series of new studies from Dartmouth Medical School in Hanover, NH. The studies appear on the Web site for the journal Health Affairs.

Researcher John Wennberg, MD, MPH, who heads Dartmouth's Center for the Evaluative Clinical Sciences (NH), found that CMS and other organizations could use Medicare claims data to measure population-based, provider-specific rates of resource inputs, utilization, and Medicare spending, and use the information to develop hospital-specific measures. The measures would help identify providers with acceptable quality indices who are also efficient at managing chronic illnesses.

Specifically, Wennberg and colleagues found that care differed sharply at the seven hosptials that U.S. News and World Report has identified as the best in the nation.

For example, patients who received most of their care from Mount Sinai Medical Center spent almost twice as many days in the hospital during the last six months of their life as patients cared for by the Mayo Clinic hospitals (St. Mary's and Rochester Methodist), the researchers found.

Meanwhile, the use of technology, measured by the number of ICU days, was three times greater for patients at the University of California, Los Angeles (UCLA) Medical Center, than for patients who received most of their hospital care at Massachusetts General hospital. In addition, patients at Mount Sinai Medical Center and UCLA experienced more than twice as many physician visits than patients at Duke University Hospital.

Other findings from the Dartmouth research team included:

  • The content, quality, and outcomes of care provided to patients with chronic illnesses differs across acute medical centers by up to 60%. "Efforts to reduce costs will require attention to supply-sensitive services (the frequency of hospital stays, physician visits, specialist consultations, diagnostic tests, and minor procedures)," concludes researcher Elliott Fisher, professor of community and family medicine, "and should include a focus on the longitudinal efficiency of hospitals and medical staffs."

  • Care varies according to a patient's race and geographical location. Whites, for example, receive nearly three times as many carotid endarterectomies as blacks, but only 30% more angiograms. Blacks have higher ICU admission rates in the last six months of their lives and are less likely than whites to receive highly effective interventions.

  • A large number of patients still undergo surgery in low-volume hospitals, despite evidence that it is less risky to undergo the procedures in higher-volume hospitals. "In many regions that lacked a high-volume hospital, there were enough overall cases to meet the volume threshold, but there were too many hospitals performing them," notes researcher Justin Dimick, a postdoctoral research fellow in the Veteran's Affairs (VA) Outcomes Group, VA Medical Center, in White River Junction, VT.

Most of the variations in costs addressed in the Health Affairs studies occurred in patients with more severe illnesses and complex medical needs--and "now we're going to implement and evaluate innovative programs to help these patients get better care," says CMS Administrator Mark McClellan. "Their care is frequently not best suited to their needs, and it's not based on the latest medical evidence."

A new Medicare demonstration will provide care management programs for high-cost beneficiaries. Currently, 15% of the Medicare population accounts for 75% of program costs.

For example, many patients with serious illnesses and high costs have pain and nutritional problems that can lower their quality of life, and that "too often leads to avoidable hospitalizations when these complications are not cared for effectively outside the hospital," he says.

CMS is also taking new steps to find, test, and disseminate systems-based solutions through the Medicare health care quality demonstration program mandated by Section 646 of the Medicare Modernization Act.

The variation studies will be available for free viewing until Oct. 22 at www.healthaffairs.org.

-- Wendy Johnson
wjohnson@hcpro.com

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