July 2008
In defense of 'more'
The Dartmouth Atlas ranked NYU Langone Medical Center in New York City No. 1 in the nation among hospitals/medical schools
for aggressive care and spending. Its chief medical officer, Robert Press, M.D., said the hospital was concerned when rankings
first came out, in the 2006 edition of the Atlas. "Following the release of the original data, we began a number of initiatives
that are still ongoing toward defining the patient's wishes at the time of admission regarding the extent of care that he
or she wants provided." But Press also notes that many patients and families served by his hospital "really desire very aggressive
care. And a number of our physicians really believe in providing aggressive care. We are changing this to the extent it can
be changed, but it is a cultural change."
Cedars-Sinai Medical Center in Los Angeles ranked second for aggressiveness of end-of-life care. Thomas M. Priselac, the hospital's president and CEO, says that while Dartmouth is doing "very important work," without more detailed hospital-specific data "it raises more questions than it provides answers."
A key question, of course, is whether patients are being kept alive longer in the regions that spend more money and deliver more aggressive care. "To judge survival, you have to look at people who are similarly ill and then follow them forward over time," says Elliott S. Fisher, M.D., Wennberg's longtime research collaborator. "And we've done that." Their study of 969,325 Medicare beneficiaries hospitalized nationwide for three common conditions—colon cancer, heart attack, and hip fracture—published in the Feb. 18, 2003, issue of the Annals of Internal Medicine, analyzed the follow-up tests and treatments the patients received for up to five years after their very similar initial treatment.
Patients in the highest-spending areas received 60 percent more treatment than those in the lowest-spending areas, but the extra care didn't seem to help at all, and it made some things worse. Patients in the high-spending, aggressive-care regions waited longer in emergency rooms and doctors' offices than patients in lower-spending regions did. They were less likely to get recommended preventive treatments, such as aspirin to prevent future heart attacks, or appropriate immunizations. They were slightly more likely to die, and those who didn't die weren't any better off in terms of their ability to function in daily life. And overall they were no more satisfied with their care.
Other research groups have had similar findings using different methods.
A state-by-state score card on health-system performance was issued in 2007 by the Commonwealth Fund, an independent health-quality research group. It graded such factors as overall population health, quality of care, access to care, and avoidable hospitalizations. Of the 13 states with the best scores, 10 have below-average end-of-life costs. And the three states in the Dartmouth study that spend the most on end-of-life health care—New York, New Jersey, and California—ranked 22nd, 26th, and 39th, respectively, in the Commonwealth Fund overall ranking.
A February 2008 study by the nonpartisan Congressional Budget Office found a reverse correlation between per capita Medicare spending and care quality. The percentage of patients hospitalized with heart attacks, pneumonia, and heart failure who get recommended treatments is lower in the higher-spending areas.
Cedars-Sinai Medical Center in Los Angeles ranked second for aggressiveness of end-of-life care. Thomas M. Priselac, the hospital's president and CEO, says that while Dartmouth is doing "very important work," without more detailed hospital-specific data "it raises more questions than it provides answers."
A key question, of course, is whether patients are being kept alive longer in the regions that spend more money and deliver more aggressive care. "To judge survival, you have to look at people who are similarly ill and then follow them forward over time," says Elliott S. Fisher, M.D., Wennberg's longtime research collaborator. "And we've done that." Their study of 969,325 Medicare beneficiaries hospitalized nationwide for three common conditions—colon cancer, heart attack, and hip fracture—published in the Feb. 18, 2003, issue of the Annals of Internal Medicine, analyzed the follow-up tests and treatments the patients received for up to five years after their very similar initial treatment.
Patients in the highest-spending areas received 60 percent more treatment than those in the lowest-spending areas, but the extra care didn't seem to help at all, and it made some things worse. Patients in the high-spending, aggressive-care regions waited longer in emergency rooms and doctors' offices than patients in lower-spending regions did. They were less likely to get recommended preventive treatments, such as aspirin to prevent future heart attacks, or appropriate immunizations. They were slightly more likely to die, and those who didn't die weren't any better off in terms of their ability to function in daily life. And overall they were no more satisfied with their care.
Other research groups have had similar findings using different methods.
A state-by-state score card on health-system performance was issued in 2007 by the Commonwealth Fund, an independent health-quality research group. It graded such factors as overall population health, quality of care, access to care, and avoidable hospitalizations. Of the 13 states with the best scores, 10 have below-average end-of-life costs. And the three states in the Dartmouth study that spend the most on end-of-life health care—New York, New Jersey, and California—ranked 22nd, 26th, and 39th, respectively, in the Commonwealth Fund overall ranking.
A February 2008 study by the nonpartisan Congressional Budget Office found a reverse correlation between per capita Medicare spending and care quality. The percentage of patients hospitalized with heart attacks, pneumonia, and heart failure who get recommended treatments is lower in the higher-spending areas.
