Jun 17, 2008

HEALTH MATTERS: Experts find 'glaring' gaps in health care

LJ Anderson / Daily News columnist

Elderly patients in Bend, Ore., spend an average of 10.6 days in the hospital in the last two years of life while comparable patients in Manhattan spend 34.9 days. Such inconsistencies are commonplace, and for more than 20 years researchers at the Dartmouth Atlas Project have analyzed the Medicare database and found "glaring," as they call it, variations in distribution and use of medical resources in the United States. Physician discretion, local practice patterns and resource availability allow for tremendous variation in how a patient is treated and how many dollars are spent.

David Goodman, M.D., M.S., is co-principal investigator of the Dartmouth Atlas (www.dartmouthatlas.org), associate director of the Center for Health Policy Research at The Dartmouth Institute for Health Policy and Clinical Practice, and professor of pediatrics at the Dartmouth Medical School.



Q: What has your research shown relative to variations in practice and use of health care resources?

A: One of the principal findings is that health care resources, utilization, and outcomes are highly dependent on where you live and receive your medical care. Health systems are widely different from place to place, and those differences are often invisible on the ground to physicians, nurses and patients. But in the Dartmouth Atlas, where we're able to examine patterns of care over many places and thousands of hospitals, those differences become evident.

The other finding is that care often falls short of what patients need or want, and it's often terrifically wasteful. For example, in looking back on the care of end-of-life patients, you find hospitals where patients get two to three times as many hospital days, days in the ICU or physician services at tremendously higher cost but for no measurable benefit. We waste money on what's unimportant and fail to invest in care that we know would improve the well-being and health of patients.

San Francisco, San Jose and Los Angeles present interesting contrasts in how care is delivered. In the last six months of life, a Medicare patient in San Francisco or San Jose spends far fewer days in the hospital, far fewer days in the ICU, and sees a smaller number of physicians - suggesting that care is more coordinated - as compared to L.A. One of the metrics we use is the percent of patients in the last six months of life who have seen 10 or more different physicians. Most patients and doctors would agree that you can't possibly keep care coordinated over that many providers. It's really quite striking how much it varies.



Q: What should patients understand about "effective care," and how do you define it?

A: There's a pretty strong consensus that "effective care" is care that has been scientifically demonstrated to increase the health and well-being of patients. An obvious example is monitoring of diabetic patients - having eye exams and blood lipids measured periodically - that leads to better outcomes.

There are many kinds of care where not only is there uncertainty about what the right decision is, but we probably will never know the answer exactly. An example of this is whether a patient with a certain level of illness is cared for within a hospital or at home. You find places where hospitalization is used two to three times more frequently with similar sorts of patients, and there are large differences in care. What we've learned in the last 15 years is that it makes little difference in how the patients actually do. There are patients who need to go into the hospital, but there's a gray zone of patients who, in some places, are admitted and in other places, are not. Billions of dollars turn on decisions that tend to be very locally based. It's important that we reduce that sort of variation, and bring it down to some of the lower benchmarks to free up money for care that we know is effective.



Q: What does an overuse of "supply-sensitive" care mean, and how does that affect patients?

A: The largest determining factor is simply whether the resources are locally available. For example, if a hospital service area has a high supply of beds relative to the population, what happens over decades is that physicians evolve their practice unconsciously to use those hospital beds. It's easy to get a patient into a hospital, so the probability is much higher that the patient will be hospitalized. There is a lot of discretion in the decisions that get made - depending on what the available supply is.

We also know that physician supply has a strong effect in terms of medical care. There's no question that having a low supply of primary care is harmful to patients. But once you go from a moderate supply of, for example, cardiologists, to a very high supply of cardiologists, there is no demonstrable benefit. What you find is that the population gets a lot more cardiac procedures. It is one thing to think that more care might not be better. It's another thing to think that more care can actually be harmful. If you're sick, for example, being in the ICU can be lifesaving, but it always comes at a price. There's an increased risk of a medical error, hospital-acquired infection, and so it has to be viewed in balance. If there isn't a lot of benefit to you being there, then you're just being exposed to the potential harms of being in that environment or receiving that procedure.



LJ Anderson writes on health matters every Tuesday. She can be reached at lj.anderson@yahoo.com.