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Assessing outcomes of high-cost care at the end of life

A lot more money is spent caring for Medicare patients in some parts of the country than in others. But regions that provide more aggressive end-of-life care don't give any better care than regions with more conservative practice patterns, nor are survival rates any higher: Those were the conclusions of two DMS studies published in the February 18 issue of the Annals of Internal Medicine.

"People assume that more medical care means better medical care," says the paper's lead author, Elliott Fisher, M.D., M.P.H. "What this study shows us is that a large fraction—perhaps a third—of medical care is devoted to services that do not improve health outcomes or the quality of care." Fisher is a professor of medicine at Dartmouth and codirector of the Outcomes Group at the Veterans Affairs Medical Center in White River Junction, Vt.

Variation: Fisher's team found that in regions with nearly identical health-care needs, the overall quantity of services provided varied by as much as 60%—from an average of $9,074 per person per year in low-spending regions to $14,644 in high-spending regions. Patients in the latter areas visited their physicians more often, made greater use of specialists, had more minor procedures, and had more frequent and/or longer hospital stays.

Some of the most dramatic differences were found in rates of services provided to seriously ill patients. For example, among patients in their last six months of life, intensive care unit days were twice as high and feeding tubes and emergency intubations were used more than twice as often in high-spending areas.

Worse: But there was no evidence of lower death rates, better functional status, or consistently better satisfaction with care for patients in the high-spending regions. On some measures—such as quality of care, access to outpatient services, and provision of preventive care like flu shots and Pap tests—higher-intensity regions actually fared worse than conservative regions.

Elliott Fisher has shown that more care is not better—and can even be worse.
Photo: Jon Gilbert Fox

While previous research has shown that the amount of money spent on health care and the number of medical services performed varies widely between regions, these Dartmouth studies are the first to comprehensively assess the impact of this variation on health-care outcomes.

"Our research points to the importance of controlling the capacity of the health-care system," says Fisher. "Most of the regional differences we found are due to the greater numbers of medical specialists and hospital beds in higher-intensity regions."

Analysis: The studies—which were funded by grants from the Robert Wood Johnson Foundation, the National Cancer Institute, and the National Institute of Aging—were based on an analysis of Medicare data from 1993 through 1995. The researchers looked at the clinical and financial data for four groups of patients in each of 306 hospital referral regions: 614,503 people hospitalized with hip fractures; 195,429 hospitalized with colon cancer; 159,393 hospitalized with heart attacks; and 18,190 typical Medicare patients who had completed a survey.

Implications: Fisher says that the studies hold implications for consumers as well as for policymakers. "For patients, our findings underscore the importance of evidence-based and conservative practice," he explains, while "for policy-makers, our research points to the importance of controlling the capacity of the health-care system."

Laura Stephenson Carter

If you would like to offer any feedback about this article, we would welcome getting your comments at DartMed@Dartmouth.edu.

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