Published in the December 2004 issue of Today’s Hospitalist
When Health Affairs published an article on its Web site in October showing tremendous variation in the volume of services that academic medical centers use in treating inpatients, the conclusion probably wasn’t a big surprise to anyone who has followed the work of researchers from Dartmouth Medical School. The group, after all, has published study after study highlighting huge differences in care across the country, and teaching hospitals are just the latest health care organizations to join the list.
The study, however, did more than track the level of services teaching hospitals provide “and how much money they presumably spend “on patient care. Researchers drilled down to find out exactly where the spending differences came from and how they affected quality of care at hospitals. Those results, not just the variation, are where the real surprises lay.
For one, hospitals that lavish more services on their patients don’t improve the quality of care. The evidence indicates just the opposite, that the quality of care at teaching hospitals that provide significantly more services may actually suffer a little.
Another surprise? The services that were driving up these hospitals’ costs weren’t big-ticket items like cardiac surgery, but what the article refers to as “supply-sensitive services.” That term refers to the frequency of physician visits and consultations by specialists, the use of diagnostic tests and minor procedures.
To conduct the study, researchers examined three groups of Medicare patients who received their initial and subsequent care at the same teaching hospital. The study focused on patients with three conditions: acute myocardial infarction, colorectal cancer and hip fracture. The study then divided hospitals into five groups based on their use of resources and services. Researchers compared how the level of resources used by high-intensity hospitals in treating each of the three groups of patients compared to their low-intensity counterparts.
The differences were significant. The highest intensity hospitals spent up to 47 percent more on care for acute myocardial infarction and 58 percent more for hip fracture.
Where did the additional resources go? Researchers found that spending on major surgical procedures was similar across the hospitals. When it came to minor services, however, those similarities disappeared. At high intensity hospitals, evaluation and management services were 56 percent to 82 percent more common, imaging services were ordered 20 percent to 26 percent more frequently, and diagnostic testing was 73 percent to 94 percent more common. (See “Where did the money go? A breakdown of spending by service,” below.)
Researchers also found that the extra use of resources provided no benefit t in terms of quality, mortality or functional outcomes. Hospitals that devoted more resources on patient care tended to miss basics like giving beta-blockers to inpatients.
As the study starkly concludes, “Patients in the higher-intensity hospitals simply spend more time in the hospital and intensive care unit; have more frequent physician visits; have more specialists involved in their care; and receive more imaging services, diagnostic testing, and minor (but not major) procedures.”
Lead author Elliott S. Fisher, MD, professor of medicine and community and family medicine at Dartmouth Medical School in Hanover, N.H., says that the study’s results raise important questions about whether hospitals can achieve the same outcomes for less money. Today’s Hospitalist talked to Dr. Fisher about the study “and what the results may mean for hospitalists.
Why did you focus on academic medical centers for this study?
Although we had seen big variations across regions in practice patterns, some people said that higher spending was due to the presence of teaching hospitals in these areas. One question was whether our regional findings were replicable at the hospital level even when you restrict them to the academic medical centers, where you think the science of clinical practice is refined and people are practicing medicine as wisely as possible. The second question was whether higher intensity hospitals are doing a better job. We wondered if at hospitals in areas that are using 30 to 50 percent less resources to care for patients, pa-
Patients are being harmed by not getting enough care. Maybe high intensity hospitals produce better outcomes.
The study points out that capacity in terms of physician workforce and available hospital beds greatly affects how physicians use resources. Why is that the case?
The major differences are not in the use of high-cost procedures that we think of as the drivers of health care spending. While major surgical procedures such as bypass surgery, bone marrow transplantation, hip replacement and knee replacement do vary dramatically across regions and hospitals, they don’t explain the differences in spending across regions. Most of the differences in spending are due to how often patients are seeing a doctor and how likely they are to see a specialist, as opposed to not see a specialist, when they’re at a given level of severity of illness.
The major differences we see at the regional level are that the high-spending regions have 75 percent more medical specialists per capita than the low-spending regions, and they also have 80 percent more physician visits, higher rates of diagnostic spending and higher rates of minor procedures. All these factors are strongly related with the local per-capita supply of medical specialists. At the hospital level, we think the same thing is going on. When you look at NYU Medical Center, as we have done in previous studies, you see that average Medicare beneficiaries in their last six months of life spend 27 days in the hospital, and that they have 80 physician visits in the last six months of life. Similar patients at Stanford University Medical Center receive less than half as much care. All our data would suggest that the level of care at NYU includes a lot of unnecessary ” and possibly harmful “care.
Hospitals with a high-intensity practice pattern are also much more likely to have a number of different physicians involved in a given patient’s care. At NYU, almost half of the seriously ill patients had 10 more or more physicians involved in their care. At Stanford, by comparison, only a fraction of patients had that number of physicians involved in their care.
The article also mentions ICU bed availability as another factor. Why would more beds in the ICU lead to a greater use of services?
This phenomenon has been observed by other researchers. If there are more beds available at the time you’re making a choice whether to admit someone to the ICU or not, the very sickest patients are likely to get in. If the physicians are less certain about whether a patient really needs to be in the ICU or not, then if there’s a bed constraint, they’ll keep the less severely ill patient on the floor. Data show that physicians manage resource constraints pretty well.
What’s a take-home message of this study for hospitalists?
There is an association in our data between higher intensity hospitals and more frequent physician visits and more different physicians involved in a given patient’s care. That association has led some to hypothesize that the lower quality observed in high spending regions of the country might reflect a problem of coordination of care.
I think there’s a real opportunity for hospitalists to improve the care of patients in both high- and low-intensity hospitals. Having 10 doctors involved in a given patient’s care may not be a good thing, unless someone is doing a really good job of coordinating that care.
Whether there needs to be 10 doctors involved in that care in the first place is another thing that hospitalists might well think about. Maybe they can manage the choice of antibiotics without consulting the ID specialist, maybe they can manage the headache the patient told me about this morning without consulting a neurologist.
I’m not sure that just adding a hospitalist to NYU Medical Center is going to change the culture or the care system. It may allow physicians to manage call better, but we need to rethink the delivery system to figure out how we can manage patients with serious chronic illness more effectively. Those data so far are suggestive that we do better in the systems that use specialists more parsimoniously.
What kinds of obstacles do hospitals face in trying to better manage resources?
There are some serious challenges about reforming the payment system. As long as physicians and hospitals depend on throughput to maintain their incomes, we are not going to be able to think about better care rather than more care.
That said, I do think that hospitals and their affiliated medical staffs are a logical group to start thinking about as a locus for reform. There’s a tremendous potential to use the hospital as the site around which we organize delivery systems.
In each of the four studies we’ve now done, once patients go through an acute episode of illness, they tend to rely on the hospital and the medical staff associated with it to get their care over the long haul. Seventy to ninety percent of care for patients who have gotten one episode of care at a hospital will end up being at the hospital for the next two years.